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PHLEBITIS    AND    THROMBOSIS 


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in  2010  with  funding  from 

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http://www.archive.org/details/phlebitisthromboOOhawa 


PHLEBITIS 
AND     THROMBOSIS 

^be  Ibunterian  ^Lectures 

DELIVERED    BEFORE    THE    ROYAL    COLLEGE    OF 
SURGEONS    OF    ENGLAND    IN    MARCH,    igo6 


BY 


WARRINGTON   HAWARD,  F.R.CS.  Eng. 

HUNTERIAN  PROFESSOR  OF  SURGERY  AND  PATHOLOGY  IN  THE  ROYAL  COLLEGE  OF  SURGEONS 

OF  ENGLAND  ;  CONSULTING  SURGEON  TO  ST.  GEORGE'S  HOSPITAL  ;  PRESIDENT  OF  THE 

ROYAL  MEDICAL  AND  CHIRURGICAL  SOCIETY 


NEW    YORK 
WILLIAM     WOOD     &     COMPANY 

MDCCCCVI 


:^ 


CONTENTS 


LECTURE  I 

Causes  of  thrombosis. — Disturbances  of  physiological  relations 
between  blood  and  vessels  by:  (i)  Changes  in  vessel — (a) 
traumatism  ;  (d)  inflammation  ;  (c)  degeneration  :  (d)  dilata- 
tion. (2)  Changes  in  blood — (a)  invasion  of  micro-organisms ; 
(^)  physical  changes  ;  (c)  chemical  changes.  (3)  Retardation 
or  arrest  of  blood-current. 

The  process  of  coagulation  :  (a)  Influence  of  the  blood-platelets  ; 
(^)  of  the  leucocytes  ;  (c)  of  the  red  corpuscles  (laky  blood); 
(d)  of  lecithin  ;  (e)  of  nucleo-albumin  ;  (/)  of  lymph  ;  (g)  of 
calcium. — Influence  of  retardation  of  current. 

Varieties  of  thrombi  :  (a)  Red  thrombi :  (3)  white  thrombi  ; 
{c)  hyaline  thrombi  ;  (d)  inflammatory  thrombi. 

The  organization  of  thrombi. — The  disintegration  of  thrombi. — • 
Septic  thrombi. 

Cardiac  thrombosis. 

Arterial  thrombosis  :  causes,  symptoms,  results. 

Venous  thrombosis  :  causes — (a)  injuries  ;  (1^)  inflammation  ;  (c)  in- 
vasion by  micro-organisms  :  (i.)  of  the  blood,  (ii.)  of  the  coats 
of  the  veins. 

Septic  phlebitis. — Phlegmasia  dolens. — Pylephlebitis. — Suppura- 
tive phlebitis. — Symptoms  of  septic  phlebitis.  —  Sources  of 
infection. — Treatment    -------- 


LECTURE  II 

Other  varieties  of  phlebitis  and  thrombosis.  —  Thrombosis  in 
connection  with — {a)  varix  ;  {d)  gout ;  (c)  syphilis  ;  (d)  enteric 
fever ;  (e)  typhus  fever  ;  (/)  chlorosis ;  (^)  influenza  ;  (A) 
pneumonia  ;  (i)  appendicitis ;  (j)  gastric  ulcer  and  other 
abdominal  diseases. — 'Idiopathic'  thrombosis. — Preference 
of  venous  thrombosis  for  left  lower  limb. 


vi  Contents 

Thrombosis  of  upper  limb. 

Pulmonary  embolism  and  thrombosis. 

Symptoms  of  non-infective  phlebitis  and  thrombosis. — Explana- 
tion of  occurrence  or  absence  of  oedema. — Results  of  venous 
obstruction  and  obliteration. — Obliteration  of  venje  cav^e 


LECTURE  III 

Thrombosis  of— (a)  cerebral  sinuses  ;  {b)  mesenteric  veins  ;  {c) 
gastric  veins ;  {d)  portal  veins ;  {e)  hsemorrhoidal  veins 
(ischiorectal  abscess)  ;  (/)  renal  veins  ;  {g)  splenic  veins  ; 
{k)  prostatic  veins  ;  (z)  corpus  cavernosum. 

Treatment  of  thrombosis  and  phlebitis. 

Remote  effects  of  thrombosis  :  their  treatment. — Importance  of 
developing  deep  collateral  veins.  —  Cause  of  enlargement 
of  the  limb. 

Effects  of  venous  obstruction  on  the  heart. 

General  management  of  cases  of  blocked  veins     -        -        -        -    62 

Index      -...--.-       85 


LIST  OF  ILLUSTRATIONS 

FIG.  TO   FACE  PAGE 

1.  OBLITERATING     ARTERITIS  :     SHOWING     COATS     OF     VESSEL 

MUCH  THICKENED,  AND  ORGANIZING  AND  ADHERENT 
CLOT    -  -  -  -  -  -  -  -        13 

2.  ARTERIAL  THROMBOSIS  :  COATS  OF  ARTERY  NOT  THICKENED, 

BUT  VESSEL  CONTAINING  ADHERENT  AND  CHANNELLED 
CLOT    --------        14 

3.  SECTION  OF  BRANCH  OF  FEMORAL  ARTERY  FROM  A  WOMAN, 

AGED  TWENTY-THREE  YEARS,  WHO  DIED  FROM  EXTEN- 
SIVE THROMBOSIS  OF  THE  PULMONARY  ARTERY:  THE 
ARTERY  FULL  OF   CLOT;   COATS   NATURAL  -  -         I? 

4.  FEMORAL   VEIN    FROM    A    CASE    OF    INFECTIVE    PHLEBITIS  :       ' 

SHOWING  GREAT  THICKENING  OF  COATS  OF  VEIN,  AND 
DISINTEGRATING  CLOT  -  -  -  -  -        23 

5.  THE  RELATIONS  OF  THE  ILIAC  ARTERIES  AND  VEINS.      THE 

LEFT  COMMON  ILIAC  VEIN  (■Z/)  IS  SEEN  CROSSED  AT  A 
RIGHT  ANGLE  BY  (a)  THE  RIGHT  COMMON  ILIAC  ARTERY 
AND    (p)  THE  LEFT  INTERNAL  ILIAC  ARTERY  -  "45 

6.  7.   PHOTOGRAPHS     SHOWING     THE    DEVELOPMENT     OF    THE 

SUPERFICIAL    VEINS    TWENTY-ONE   YEARS    AFTER    OBLIT- 
ERATION OF  PART  OF  THE  INFERIOR  VENA  CAVA  -        59 
8.  THROMBOSIS    OF   FEMORAL  VEIN,   BUT    NO   THICKENING    OF 

VENOUS   COATS  -  .    -  -  -  -  "75 

The  micro-photographs  Figs,  i,  2,  3,  4,  and  8,  are  by  Dr. 
H.  R.  D,  Spitta.  The  photographs  Figs.  6  and  7  are  by 
Mr.  C.  H.  Frankau. 


LECTURE  I 

Causes  of  thrombosis. — Disturbances  of  physiological  relations  between 
blood  and  vessels  by  :  (i)  Changes  in  vessel — {a)  traumatism  ;  {b)  in- 
flammation ;  {c)  degeneration  ;  {d)  dilatation.  (2)  Changes  in  blood 
— {a)  invasion  of  micro-organisms ;  {b)  physical  changes  ;  {c)  chemical 
changes.     (3)  Retardation  or  arrest  of  blood-current. 

The  process  of  coagulation  :  {a)  Influence  of  the  blood-platelets  ; 
{b)  of  the  leucocytes  ;  {c)  of  the  red  corpuscles  (laky  blood)  ;  {d)  of 
lecithin  ;  {e)  of  nucleo-albumin  ;  {/)  of  lymph  ;  (g)  of  calcium. — 
Influence  of  retardation  of  current. 

Varieties  of  thrombi  :  (a)  Red  thrombi  ;  {b)  white  thrombi  ;  {c)  hyaline 
thrombi ;  {d)  inflammatory  thrombi. 

The  organization  of  thrombi. — The  disintegration  of  thrombi. — Septic 
thrombi. 

Cardiac  thrombosis. 

Arterial  thrombosis  :  causes,  symptoms,  results. 

Venous  thrombosis  :  causes — {a)  injuries  ;  {b)  inflammation  ;  {c)  in- 
vasion by  micro-organisms  :  (i.)  of  the  blood,  (ii.)  of  the  coats  of 
the  veins. 

Septic  phlebitis. — Phlegmasia  dolens. — Pylephlebitis. — Suppurative 
phlebitis. — Symptoms  of  septic  phlebitis. — Sources  of  infection. — ■ 
Treatment. 

Mr.  President  and  Gentlemen, — It  has  always  seemed 
to  me  that  our  interest  in  a  disease  should  be  in  proportion, 
not  to  the  rarity,  but  to  the  commonness  of  its  occurrence. 
It  is  true  that  the  careful  investigation  of  an  unusual 
affection  may  throw  a  light  upon  some  pathological  pro- 
cess which  is  common  to  other  diseases,  and  thus  give  a 
wider  significance  than  would  at  first  appear  to  belong  to 
such  observations ;  but  surely  the  study  of  conditions 
which  we  are  frequently  called  upon  to  treat  must  possess 

I 


2  Phlebitis  and  Thrombosis 

for  us  a  still  greater  importance.  I  have  therefore  ventured 
to  devote  the  lectures  which  I  have  the  honour  to  deliver 
here  to  the  subject  of  thrombosis  and  phlebitis,  conditions 
which  are  of  no  uncommon  occurrence,  and  concerning 
which  there  yet  appear  to  me  to  be  some  points  worthy  of 
consideration. 

I  am  the  more  encouraged  to  ask  your  attention  to  this 
topic  because,  having  for  some  years  been  making  and 
collecting  observations  relating  to  thrombosis,  I  have 
found  that  the  remoter  effects  of  the  disease  do  not  seem 
to  have  attracted  much  attention  from  surgeons. 

Coagulation  of  blood  within  the  living  vessels  occurs 
under  a  variety  of  conditions,  of  which  the  mode  of  origin 
is  in  some  cases  well  understood  and  sufficiently  obvious, 
while  of  others  it  is  obscure  and  difficult  to  explain. 

A  thrombus  may  be  the  result  or  the  cause  of  inflamma- 
tion of  the  containing  vessel ;  it  may  be  determined  by  a 
change  in  the  blood  or  by  a  change  in  the  vessel  which 
contains  the  blood. 

As  the  fluidity  of  the  blood  and  its  proper  circulation 
depend  upon  the  maintenance  of  the  normal  physiological 
relations  between  the  blood  and  the  vessels,  conditions 
which  disturb  these  relations  will  give  rise  to  thrombosis. 
The  most  obvious  of  such  disturbing  conditions  are 
traumatic.  A  wound,  laceration,  or  contusion  of  a  blood- 
vessel may  lead  to  the  formation  of  a  thrombus  by  inter- 
fering with  the  integrity  of  the  vessel  wall.  Other  injuries, 
such  as  burns  and  fractures,  neighbouring  irritation  or 
suppuration,  or  anything  giving  rise  to  inflammation  of 
the  vessel,  are  causes  of  thrombosis.  So  also  degeneration 
of  the  arterial  or  venous  coats,  dilatations,  aneurisms,  and 
varices,  pressure  or  other  causes  of  retardation  or  arrest 
of  the  blood -stream  in  the  vessel  and  in  the  vasa  vasorum, 
may  give  rise  to  the  formation  of  a  thrombus. 


Phlebitis  and  Thrombosis  3 

Other  causes  of  thrombosis  are  changes  in  the  blood,  of 
which  some  of  the  most  important  are  due  to  the  invasion 
of  micro-organisms.  There  is  an  increased  tendency  to 
coagulation  of  the  blood  in  anaemia  and  chlorosis;  in 
phthisis  and  other  debilitating  diseases  ;  in  certain  acute 
diseases  ;  after  fevers,  haemorrhage,  and  long-continued 
suppuration  ;  and  in  conditions  of  exhaustion. 

The  process  of  coagulation  has  been  much  discussed, 
and  the  relative  importance  of  the  factors  in  its  production 
is  still  undetermined.  The  presence  of  fibrinogen  and 
fibrin  ferment  is  certainly  essential,  and  probably  also  the 
presence  of  a  soluble  salt  of  calcium  ;  but  the  source  of 
the  fibrin  ferment  remains  a  matter  of  dispute.  Cohnheim 
and  others  have  maintained  that  the  leucocytes  play  the 
chief  part  in  the  process  of  thrombosis ;  Schmidt  of 
Dorpat  and  his  followers  stating  that  the  leucocytes  by 
disintegration  form  fibrino-plastin  or  paraglobulin  and 
the  ferment,  the  fibrinogen  existing  naturally  in  the 
blood-plasma ;  while,  on  the  other  hand,  Eberth  and 
Schimmelbusch,  followed  by  numerous  other  observers, 
attribute  the  greater  importance  to  the  blood-platelets. 

This  much  may,  I  think,  with  some  confidence  be 
stated  :  that  healthy  blood  contained  in  normal  vessels 
consists  of  a  fluid  (the  plasma)  which  holds  in  solution 
a  proteid  material  (fibrinogen).  In  this  fluid  are  suspended 
the  red  corpuscles,  the  various  colourless  corpuscles,  and 
the  blood-platelets.  That  if  the  normal  relations  between 
the  blood  and  the  vessels  are  disturbed,  coagulation  may 
occur,  and  this  involves  the  appearance  in  the  blood 
(probably  from  changes  in  the  colourless  corpuscles  and 
platelets)  of  a  nucleo-proteid,  which,  with  a  soluble  salt  of 
calcium,  forms  fibrin  ferment ;  and  this,  acting  upon  the 
fibrinogen  of  the  plasma,  leads  to  the  formation  of  fibrin, 
which,  with  the  entangled  corpuscles,  forms  the  clot. 

I — 2 


4  Phlebitis  and  Thrombosis 

There  has  been  a  good  deal  of  difference  of  opinion  as 
to  the  origin  and  function  of  the  platelets,  some  observers 
maintaining  that  they  do  not  exist  in  normal  blood,  but 
are  the  result  of  the  disintegration  of  the  corpuscles  ; 
others  that  they  may  exist  in  normal  blood,  but  that  they 
are  derivatives  of  the  leucocytes  or  of  the  red  corpuscles  ; 
others,  again,  that  they  are  the  progenitors  of  the  red 
corpuscles.  But  the  tendency  of  recent  researches  has 
been  to  regard  the  platelets  as  independent  elements  of 
the  blood,  and  to  attribute  to  them  an  important  influence 
in  the  process  of  coagulation.  The  evidence  in  this  direc- 
tion seems  to  me  to  be  convincing. 

Although  the  blood-plates  were  described  as  long  ago 
as  1842  by  Donne,  in  a  paper  on  the  origin  of  the  cor- 
puscles of  the  blood,^  and  various  theories  concerning 
them  were  promulgated  from  time  to  time,  it  was 
Bizzo^ero's"  paper,  published  in  1882,  which  aroused  a 
fresh  interest  in  these  bodies  and  led  to  much  new  in- 
vestigation. Bizzozero  maintained  that  the  blood-plates 
were  definite  and  regular  elements  of  the  normal  circulating 
blood,  and  though  this  was  disputed  by  other  observers, 
his  observations  have  since  been  abundantly  confirmed. 

Professor  Osler,^  in  his  '  Cartwright  Lectures  on  the 
Physiology  of  the  Blood  Corpuscles,'  published  in  1886, 
records  a  number  of  interesting  observations  upon  the 
blood-plates.  He  agrees  with  Bizzozero  that  they  are 
normal  elements  of  the  blood,  and  he  points  out  that  their 
tendency  to  agglutinate  and  to  undergo  rapid  changes 
when  the  normal  conditions  are  disturbed  renders  them 

^  Comptes  Re72dus  de  I'Acadhnie  des  Sciences,  1842,  p.  366. 

^  Bizzozero,  VircJiow's  Archiv,  vol.  xc,  p.  261. 

^  Osier,  '  Cartwright  Lectures  on  the  Physiology  of  the  Blood 
Corpuscles,'  Medical  News,  Philadelphia,  1886,  p.  365.  See  also 
Osier  on  the  '  History  of  Blood-platelets,'  Johns  Hopkins  Hospital 
Bulletin,  May,  1905. 


Phlebitis  and  Thrombosis  5 

extremely  difficult  to  observe,  and  that  this  may  account 
for  the  discrepancies  in  the  descriptions  of  various 
observers.  This  agglutination  is  quite  different  from  that 
of  the  red  corpuscles  ;  they  do  not  form  rouleaux,  but 
become  fused  together  in  a  granular  mass.  Professor 
Osier  gives  the  relative  number  of  the  plates  as  about 
I  to  i8  or  20  of  the  red  corpuscles  (a  lower  estimate  than 
most  observers),  and  he  found  that  the  number  varied 
in  conditions  of  disease.  In  the  formation  of  a  thrombus 
he  observed  that  the  blood-plates  were  the  first  elements 
which  collect  upon  the  vessel  wall,  and  that  in  the  process 
of  coagulation  the  fibrin  filaments  spread  chiefly,  though 
not  exclusively,  from  the  plate  masses  as  centres.  He  saw 
no  indication  whatever  of  the  disintegration  of  leucocytes. 
Dr.  Robert  Muir,^  in  his  papers  on  '  The  Physiology  and 
Pathology  of  the  Blood,'  published  in  the  Journal  of 
Anatomy  and  Physiology  for  1891,  has  given  a  most  careful 
description,  with  beautiful  drawings,  of  the  blood-plates, 
together  with  directions  as  to  the  best  way  of  observing 
them.  In  fresh  undiluted  normal  blood,  examined  a  few 
seconds  after  withdrawal  from  the  vessels,  he  found 
numerous  blood-plates  among  the  red  and  white  cor- 
puscles. He  describes  them  as  round  or  oval  disc-like 
bodies,  about  one-fourth  the  diameter  of  a  red  corpuscle, 
slightly  convex,  faintly  granular,  and  colourless.  His 
observations  show  that  in  their  staining  reactions,  in  their 
structure,  and  in  their  chemical  composition  they  differ 
from  all  the  other  elements  of  the  blood,  and  that  they 
have  definite  characters  peculiar  to  themselves.  In  shed 
blood  they  rapidly  undergo  certain  changes  connected 
with  the  process  of  coagulation.  They  become  adhesive, 
stellate,  more  granular  and  refractive,  and  are  soon  aggre- 

^  '  The  Physiology  and  Pathology  of  the  Blood/  by  Dr.   Robert 
yivivc,  Journ.  of  Anat.  and  Physiol.^  1891,  vol.  xxv.,  p.  256. 


6  Phlebitis  and  Thrombosis 

gated  into  small  groups.  After  about  three  minutes  the 
formation  of  fibrin  commences,  delicate  threads  of  which 
appear  round  the  groups  of  altered  blood-plates.  These 
changes  can  be  prevented  or  retarded  by  various  methods 
v^^hich  prevent  the  coagulation  of  the  blood,  such  as  the 
addition  of  neutral  salt  solutions,  or  exposing  the  blood 
to  a  low  temperature.  On  the  other  hand,  if  a  foreign 
body  is  introduced  into  the  living  vessels,  or  if  the  vessel 
by  injury  or  otherwise  loses  its  normal  condition,  the  blood- 
plates  undergo  the  same  changes  that  they  do  outside  the 
vessels,  adhering  to  each  other,  to  the  foreign  body,  and 
to  the  vessel  wall,  and  becoming  fused  together  into  a 
granular  mass  which  is  the  starting-point  of  a  thrombus. 

Professor  G.  T.  Kemp  and  Miss  H.  Calhoun  communi- 
cated some  important  observations  with  regard  to  the 
blood-plates  to  the  International  Congress  of  Physiolo- 
gists at  Turin  in  igoi.^  As  the  result  of  seventy-five 
observations  on  nineteen  different  individuals,  they  esti- 
mated the  average  number  of  platelets  in  normal  blood  as 
778,000  per  cubic  millimetre.^  The  number  bore  no 
definite  relation  to  the  number  of  leucocytes,  but  the 
ratio  to  the  number  of  red  corpuscles  was  fairly  constant. 
The  connection  of  the  blood-platelets  and  the  leucocytes 
with  coagulation  was  determined  by  a  method  which  the 
authors  proposed  to  name  '  fractional  defibrination.' 

A  certain  fraction  of  the  calculated  blood  of  an  animal 
was   drawn,   defibrinated,   filtered,   and   returned   to   the 

1  Reported  in  Brit.  Med.  Journ.,  1901,  vol.  ii.,  p.  1539. 

'^  It  will  be  remembered  that  in  normal  blood  the  number  of  leuco- 
cytes per  cubic  miUimetre  is  about  10,000;  the  number  of  red  corpuscles 
per  cubic  miUimetre  is  about  5,000,000.  Messrs.  Brodie  and  Russell 
estimated  the  number  of  blood-platelets  as  635,300  per  cubic  milli- 
metre, or  I  :  8*5  of  red  corpuscles.  Dr.  J.  H.  Pratt,  of  Boston, 
United  States  of  America  {Jourti.  of  Amer.  Med.  Assoc,  December  30, 
1905,  p.  1999),  gives  the  average  number  of  platelets  per  cubic  milli- 
metre as  469,000. 


Phlebitis  and  Thrombosis  7 

circulation.  This  process  was  repeated  until  fibrin  was 
no  longer  formed.  At  each  stage  the  red  corpuscles,  the 
leucocytes,  and  the  platelets  were  counted.  The  platelets 
disappeared  progressively  with  each  defibrination,  and 
after  the  blood  ceased  to  be  coagulable  (from  the  sixth  to 
the  tenth  defibrination)  they  were  no  longer  present. 
The  leucocytes  disappeared  to  some  extent,  but  never 
completely.  The  red  corpuscles  suffered  some  diminution, 
but  much  less  than  the  leucocytes. 

The  platelets  were  seen  to  be  bi-concave,  but  they  were 
never  found  to  contain  traces  of  hsemoglobin,  and  there- 
ore  could  not  be  regarded  as  hsematoblasts  in  Hayem's  ^ 
sense.  Their  micro-chemical  reactions  resembled  to 
some  extent  those  of  red  corpuscles,  and  also  those  of  the 
nuclei  of  leucocytes,  but  were  identical  with  neither. 
The  authors  agreed  with  Bizzozero  that  they  were  inde- 
pendent elements  of  the  blood. 

Dr.  A.  Petrone  (of  Naples)  at  the  same  Congress  related 
researches  pointing  to  the  same  conclusions  as  to  the 
independence  of  the  blood-platelets  as  separate  elements 
of  the  blood. 

Wooldridge  remarks  in  this  connection  :  '  Blutplattchen 
are  regarded  by  all  observers  who  have  attacked  the 
problem  as  definite  form  elements,  by  which  I  understand 
them  to  mean  organized  bodies  ;  and  it  is  difficult  to 
know  how  else  to  regard  them,  for  they  have  just  as 
much  right  to  be  regarded  as  form  elements  as  the  red 
corpuscles  have.  Many  attribute  to  these  bodies,  in  regard 
to  coagulation,  the  powers  which  Schmidt  has  referred  to 
the  white  corpuscles.     I  think  they  are  perfectly  right.'  ^ 

^  Dr.  Robert  Muir  came  to  the  same  conclusion  as  to  Hayem's 
theory  {op.  cii.,  p.  500). 

^  Wooldridge,  '  The  Chemistry  of  the  Blood,  and  other  Papers,' 
edited  by  Horsley  and  Starling,  1893,  p.  177. 


8  Phlebitis  and  Thrombosis 

But  Wooldridge  ^  maintained  that  fibrin  could  also  be 
produced  as  the  result  of  an  interaction  between  two  or 
more  fluid  fibrinogens  or  proteid-lecithin  compounds  of 
different  chemical  composition,  of  which  interaction  the 
fibrin  ferment  is  a  by-product ;  and  he  drew  attention 
to  the  important  part  played  by  lecithin  in  the  process  of 
coagulation. 

Professor  W.  D.  Halliburton  and  Mr.  T.  G.  Brodie  ^ 

have    shown    that    nucleo-albumin,    free   from    lecithin, 

obtained  from  the  tissues  of  various  organs,  when  injected 

into   the   circulation   of  rabbits,  produces    instantaneous 

and  fatal  coagulation  of  the  blood ;  and  they  consider  it 

probable  that  in  cases  of  fatal  and  extensive  thrombosis 

occurring  in  the  human  subject,  death  may  be  due  to  the 

entrance  into  the  blood  of  the  same  material. 

' .  .   .  with  a  sudden  vigour  it  doth  posset 
And  curd,  hke  eager  droppings  into  milk, 
The  thin  and  wholesome  blood.'  ^ 

Moreover,  Professor  A.  E.  Wright  has  proved  that  the 
addition  of  lymph  to  blood  notably  accelerates  coagula- 
tion,^ '  and  that  the  administration  of  chloride  of  calcium 

After  I  had  written  these  lectures,  my  friend  Dr.  G.  A.  Buckmaster 
kindly  allowed  me  to  read  the  proofs  of  part  of  a  lecture  in  which  he 
treats  of  the  origin  of  the  blood-platelets,  and  records  his  investigations 
into  the  subject  ('The  Morphology  of  Normal  and  Pathological  Blood,' 
by  G.  A.  Buckmaster,  M.D.  ;  Murray,  1906).  Dr.  Buckmaster  has 
come  to  the  conclusion  that  blood-platelets  do  not  exist  in  normal 
living  blood,  but  are  pathological  or  artificial  products.  I  have  the 
greatest  respect  for  Dr.  Buckmaster's  views,  but  I  do  not  understand 
how  his  negative  observations  invalidate  those  of  observers  (Eberth  and 
Schimmelbusch)  who  have  seen  the  platelets  in  the  vessels  of  the  living 
mesentery,  or  (Laker)  in  the  membrane  of  the  wing  of  the  young  bat. 

1  Wooldridge,  op.  a'/.,  pp.  190,  241.  This  statement  was  based  on 
observations  made  with  'peptone  plasma/  and  was  controverted  by 
Halliburton  and  others.     See/ourn.  of  Physiol.,  vol.  ix.,  p.  270. 

2  Brit.  Med.  Joiirti.,  1893,  vol.  ii.,  p.  682. 

^  '  Hamlet,'  I.  v.  68.  ^  Journ.  of  Physiol.,  vol.  xxviii.,  p.  514. 


Phlebitis  and  Thrombosis  9 

has  a  most  marked  effect  in  increasing  the  coagulabiHty  of 
the  blood  in  the  hving  subject.'^ 

Evidently,  therefore,  the  chemical  composition  of  the 
blood  may  have  an  important  influence  in  diminishing  or 
increasing  the  tendency  to  coagulation. 

Wooldridge  ^  showed  that  the  injection  of  laky  blood — 
i.e.,  blood  in  which  the  red  corpuscles  have  been  dissolved 
— gives  rise  to  intravascular  clotting,  and  that  the  active 
agent  is  not,  as  used  to  be  thought,  the  hsemoglobin,  but 
the  stromata  of  the  red  corpuscles,  the  protoplasmic 
framework  in  whose  meshes  the  haemoglobin  is  contained, 
and  which  is  a  complex  proteid-lecithin  compound. 

Wooldridge's  work  in  relation  to  the  chemistry  of 
coagulation  is  extremely  suggestive,  and  although  his 
conclusions  are  not  all  universally  accepted,  his  papers 
are  well  worth  careful  study.  The  chemistry  of  the  blood 
is  an  investigation  of  extreme  difficulty,  because  directly 
the  blood  is  removed  from  the  bloodvessels  it  undergoes 
important  changes  ;  so  that  it  is  difficult  to  reason  from 
experiments  in  the  laboratory  to  the  vital  chemistry  of  the 
living  body. 

As  Wooldridge  said :  *  Genetically  considered,  both 
blood  and  endothelium  are  differentiations  of  one  and  the 
same  protoplasmic  mass.  The  blood  is  merely  the  more 
fluid  central  part  of  the  originally  solid  protoplasmic  cord. 
The  blood  and  the  vascular  wall  may,  then,  be  looked  upon 
as  a  protoplasmic  unit.  That  the  vascular  wall  exerts  a 
great  influence  on  the  blood  is  evident  from  the  fact  that 
the  blood  undergoes  changes  which  finally  terminate  in 
coagulation,  so  soon  as  it  leaves  the  vascular  wall.'^ 

^  Brit.  Med.  Journ.,  July  29,  1893,  p.  223,  and  July  14,  1894,  p.  57  : 
Lancet,  October  14,  1905,  p.  1096. 
^  Wooldridge,  'The  Chemistry  of  the  Blood,'  p.  167. 
^  Ibid.,  p.  180. 


lo  Phlebitis  and  Thrombosis 

Hunter  1  said:  '  It  must  be  evident  that  the  fluid  state 
of  the  blood  is  connected  with  the  Hving  vessels,  which  is 
its  natural  situation,  and  with  motion.'  And  again : 
*  While  the  blood  is  circulating  it  is  subject  to  certain 
laws  to  which  it  is  not  subject  when  not  circulating.'  ^ 

Recent  investigations  show  that  the  first  stage  in  the 
formation  of  a  thrombus  is  the  accumulation  and  viscous 
change  of  the  blood-platelets,  which  adhere  to  each  other 
and  to  the  wall  of  the  containing  vessel ;  to  these  are 
soon  added  numerous  leucocytes  ;  fibrin  ferment  is  set 
free,  and  fibrin  appears,  entangling  more  or  less  of  the  red 
corpuscles. 

It  is  evident  that  this  process  will  be  favoured  by  a 
retardation  of  the  blood-stream  ;  while,  on  the  other  hand, 
in  the  large  arteries  near  the  heart,  where  the  current  is 
powerful,  small  quantities  of  clot  will  be  easily  swept 
away,  and  a  thrombus  less  easily  formed.  This,  more- 
over, is  in  accordance  with  clinical  experience,  for  throm- 
bosis is  more  common  in  veins  than  in  arteries,  and  it  is 
specially  prone  to  occur  in  positions  in  which  the  circula- 
tion is  apt  to  be  impeded. 

Moreover,  von  Recklinghausen  has  directed  attention  to 
the  manner  in  which  thrombosis  is  favoured  by  the  eddies 
produced  in  the  blood-stream  by  cross  currents,  irregulari- 
ties of  surface,  and  variation  in  the  size  of  the  vessels,  and 
by  obstruction  to  the  blood-flow.  Retardation  or  arrest 
of  the  blood-current,  although  favouring  the  occurrence 
of  thrombosis,  is  not  in  itself  sufficient  to  cause  it ;  for  it 
has  been  shown  by  Baumgarten  that  healthy  blood  will 
remain  fluid  for  weeks  or  months,  though  shut  off  from  the 
circulation  in  a  vessel  between  two  carefully  applied 
aseptic  ligatures. 

^  'Treatise  on  the  Blood,'  etc.,  p.  24,  1794. 
2  Ibid.,  p.  85. 


Phlebitis  and  Thrombosis  ii 

But  free  circulation  is  necessary  for  the  nutrition  both 
of  the  blood  and  the  vessels.  Slowing  of  the  current, 
therefore,  by  diminishing  the  normal  influence  of  the 
lining  membrane  of  the  vessels  upon  the  blood-cells,  and 
by  lowering  their  vitality,  may  set  free  the  fibrin  ferment 
and  thus  lead  to  thrombosis. 

Eberth  and  Schimmelbusch,^  moreover,  have  observed 
that  in  the  normal  blood-current  the  platelets  travel  with 
the  red  corpuscles  in  the  axial  stream,  while  the  white  cells 
move  in  the  outer,  slower  stream.  A  slight  retardation 
leads  to  an  increase  in  the  number  of  white  cells  in  the 
outer  zone,  but  not  to  thrombosis  ;  but  on  a  further  slow- 
ing of  the  current  the  platelets  are  found  in  the  peripheral 
stream  and  in  contact  with  the  endothelium,  and  it  is 
upon  these  collections  of  platelets  that  the  fibrin  is  first 
deposited  which  is  the  commencement  of  a  thrombus. 

It  would  seem,  then,  that  thrombosis  may  depend  upon 
a  variety  of  conditions,  and  is  usually  due  to  a  combination 
of  several. 

Lesions  and  degeneration  of  the  vessel  walls,  impaired 
nutrition  of  the  endothelium,  retardation  of  the  blood- 
current,  changes  in  the  composition  of  the  blood  and  in 
the  proportion  of  its  formed  elements,  the  invasion  of 
micro-organisms — any  or  all  of  these  may  play  a  part  in  the 
process,  the  predominant  factor  varying. 

If  the  movement  of  the  blood  in  a  vessel  is  arrested,  as 
by  a  ligature,  the  coagulum  formed  from  the  stagnating 
blood  consists  of  fibrin,  together  with  both  red  and  white 
corpuscles,  and  resembles  microscopically  a  clot  formed 
in  blood  outside  the  vessels  ;  it  is  of  red  colour  and  is 
spoken  of  as  a  red  thrombus. 

If  the  thrombus  is  formed  from  blood  in  motion  it  is 
usually  of  gray  colour  (the  so-called  white  thrombus),  and 

^   Virchozvs  Archiv,  vol.  ciii.,  p.  39. 


12  Phlebitis  and  Thrombosis 

consists  of  fibrin,  leucocytes,  and  blood-platelets.  A  clot 
thus  formed  may,  however,  entangle  a  variable  number  of 
red  corpuscles,  which  will  give  to  it  a  more  or  less  red 
colour. 

Professor  Welch  ^  has  described  the  characters  of 
thrombi  produced  experimentally  from  the  circulating 
blood :  '  The  material  composing  the  youngest  of  such 
thrombi  appears  macroscopically  as  a  soft,  homogeneous, 
gray,  translucent  substance  of  viscid  consistence.  Micro- 
scopically, it  is  made  up  chiefly  of  platelets,  which  are 
seen  as  pale,  round,  or  somewhat  irregular  bodies,  varying 
in  size,  but  averaging  about  one  quarter  the  diameter  of  a 
red  corpuscle.'  Then,  leucocytes  collect  at  the  margins  of 
the  platelet  masses  and  between  them.  '  These  leucocytes 
are  nearly  all  polynuclear,  and  usually  present  no  evidence 
of  necrosis  or  disintegration.'  With  the  accumulation  of 
leucocytes,  fibrillated  fibrin  makes  its  appearance  at  the 
margins  of  the  masses  of  platelets.  At  the  end  of  half  an 
hour  a  thrombus  maybe  composed  of  platelets,  leucocytes, 
and  fibrin,  with  entangled  red  corpuscles. 

Professor  Osier  ^  also  examined  the  structure  of  white 
thrombi,  and  found  that  they  consisted  chiefly  of  blood- 
plates.  The  thrombi,  for  instance,  which  form  upon 
rough  patches  upon  the  aorta,  are,  he  says,  '  without 
exception  composed,  not  of  colourless  corpuscles,  nor  of 
a  reticulated  fibrin  network,  but  almost  exclusively  of 
plaques,  which  in  the  deeper  parts  have  undergone 
granular  disintegration,  but  in  the  superficial  parts  still 
retain  their  normal  shape  and  appearance.'  Bizzozevo 
and  Hayem  have  confirmed  this  statement.  The  soften- 
ing which  occurs  in  the  centre  of  these  thrombi  is  due 

■^  '  The  Structure  of  White  Thrombi,'  Trans.  Path.  Soc.  of  Phila- 
delphia, 1887,  p.  281. 

^  '  Cartwright  Lectures  on  the  Physiology  of  the  Blood-Corpuscles,' 
Med.  News  (Philadelphia),  1886,  pp.  365,  421,  424. 


^ 


'A 


-;* 


FIG.    I. — OBLITERATING   ARTERITIS:     SHOWING    COATS    OF    VESSEL   MUCH    THICKENED, 
AND    ORGANIZING    AND   ADHERENT    CLOT. 

{To /ace J).  13.  . 


Phlebitis  and  Thrombosis  13 

to  the  liquefaction  of  the  blood-plates.  Such  a  thrombus, 
starting  in  a  vein  from  some  point  of  injury,  or,  as  often 
happens,  forming  above  the  point  of  attachment  of  a  valve, 
extends  to  a  variable  distance  chiefly  in  the  direction  of 
the  blood-current.  Thrombosis  may  be  simultaneously 
of  wide  extent,  or  the  process  may  spread  gradually  along 
the  vessel  towards  the  heart,  obstructing  long  tracts  of 
vein  and  giving  rise  to  very  extensive  propagation  of  the 
thrombus.  Extensive  thrombi  thus  formed  will  present 
alternations  of  white  and  red  thrombus.  The  original  white 
thrombus,  extending  across  the  vessel,  forms  a  barrier  to 
the  blood-current ;  stagnation  occurs  as  far  as  the  next 
branch,  and  thus  a  red  thrombus  is  added  to  the  white  ; 
upon  this  the  circulating  blood  deposits  fresh  white 
thrombus,  until  stasis  and  coagulation  again  take  place. 

A  third  variety  of  thrombus  is  the  hyaline  thrombus,  which 
consists  of  colourless,  translucent,  homogeneous  material, 
which  stains  after  the  manner  of  fibrin.  This  is  found 
chiefly  in  the  capillaries  and  small  vessels,  and  is  usually 
associated  with  infective  diseases. 

The  small  vessels  of  acutely  inflamed  tissues  may  be 
found  obstructed  by  thrombi  consisting  almost  entirely 
of  polynuclear  leucocytes  ;  or  sometimes,  as  in  hepatized 
lung,  the  vessels  may  be  occupied  by  purely  fibrinous 
coagula.  But  these  are  of  inflammatory  origin,  and  of  quite 
different  significance  to  the  thrombi  above  described. 

If  there  is  no  infection  of  the  blood  a  thrombus  may 
become  organized,  or  it  may  undergo  disintegration  and 
be  carried  away  in  the  blood-stream  without  doing  any 
harm. 

The  organization  of  a  thrombus  is  accomplished  by 
the  shrinking  and  cracking  of  the  clot,  into  the  fissures  of 
which  leucocytes  pass  from  the  vessel  wall,  and  capillaries 
extend  from  the  vasa  vasorum.     By  this  mieans  the  clot 


14  Phlebitis  and  Thrombosis 

is  gradually  absorbed,  and  its  place  taken  by  newly-formed 
connective  tissue,  which  is  adherent  to  the  lining  of  the 
vessel,  and  which,  shrinking  after  the  manner  of  scar 
tissue,  becomes  less  and  less  vascular,  until  only  a  fibrous 
cord  remains  (Fig.  i). 

The  thrombus,  thus  organized,  may  adhere  in  a  layer 
of  varying  thickness  to  the  vessel  wall,  or  may  form  a 
plug  completely  occluding  the  vessel ;  or  a  channel  may 
be  formed  through  its  centre,  or  between  the  clot  and 
some  part  of  the  vessel  wall,  leaving  the  vessel  with  a 
thickened  wall  and  diminished  lumen  (Fig.  2). 

If  disintegration  of  a  thrombus  occurs,  softening  begins 
in  the  centre  or  at  the  end  of  the  clot,  and  extends  until 
the  whole  is  broken  up  into  a  finely  granular  debris,  which 
is  carried  away  in  the  circulating  blood. 

This  is  a  process  which  is  frequently  to  be  observed, 
especially  in  varicose  veins,  and  does  not  usually  give  rise, 
when  the  clot  is  not  infective,  to  any  serious  symptoms  ; 
but  if  the  whole,  or  a  considerable  fragment  of  a  clot, 
becomes  dislodged  and  carried  into  the  circulation, 
dangerous  embolism  may  occur,  with  results  that  will  be 
described  later  on. 

Softening  commencing  in  the  centre  of  a  thrombus 
does  not  always  lead  to  its  complete  disintegration,  but 
may  result  in  the  production  of  a  thick,  greasy,  brown 
fluid,  completely  shut  in  by  the  outer  layers  of  the 
thrombus.  The  enclosed  fluid,  somewhat  resembling, 
and  formerly  mistaken  for,  pus,  consists  of  the  granular 
and  oily  debris  of  the  broken-down  corpuscles,  coloured  by 
blood  pigment. 

Occasionally  calcareous  changes  occur  in  thrombi,  giving 
rise  to  phleboliths,  concretions  consisting  principally  of 
phosphate  of  lime  with  about  20  per  cent,  of  proteid 
matter,  and  a  little  sulphate  of  lime  and  potash.    Although 


FIG.    2. — ARTERIAL   THROMBOSIS:     COATS   OF    ARTERY    NOT   THICKENED, 
BUT   VESSEL    CONTAINING    ADHERENT   AND    CHANNELLED    CLOT. 


[Tojace  p.  14. 


Phlebitis  and  Thrombosis  15 

sometimes  met  with  in  arterial  thrombi,  they  are  found 
chiefly  in  the  dilated  pouches  of  the  veins  of  the  lower 
extremities  and  pelvis.^ 

In  septic  thrombi  softening,  disintegration,  and  true 
suppuration  may  occur  ;  and  fragments  of  the  infected 
thrombus  are  carried  in  the  blood-stream  to  distant 
parts,  where,  as  septic  emboli,  they  become  centres  of 
fresh  infection. 

In  the  heart,  thrombi  form  upon  the  inflamed  valves, 
forming  the  vegetations  of  endocarditis.  Thrombi  are 
also  found  in  the  cavities  of  the  heart,  especially  in  the 
auricular  appendices,  sometimes  attached  and  sometimes 
free,  in  the  latter  case  giving  origin  to  the  so-called  '  ball 
thrombi.'^ 

Cardiac  thrombosis,  however,  falls  under  the  care  of  the 
physician,  and  I  shall  not  further  allude  to  it. 

Arterial  Thrombosis. 

This  is  met  with  in  connection  with  wounds,  injuries, 
and  degenerations  of  the  arterial  walls.  It  may  occur 
gradually,  as  in  aneurisms,  or  suddenly,  as  a  result  of 
embolism  or  other  mechanical  obstruction  to  the  blood 
current. 

It  is  also  caused  by  chronic  or  acute  arteritis,  such  as  is 

^  Dr.  Rolleston  has  recorded  an  instance  of  numerous  small 
phleboliths  under  the  skin  of  both  shins  of  a  woman  aged  fifty.  The 
phleboHths  formed  discrete,  hard,  painless,  movable  nodules,  of  the 
size  of  minute  shot  or  less  ;  they  were  not  attached  to  the  bone  or  to 
the  skin,  and  they  somewhat  resembled  the  subcutaneous  nodules 
seen  in  connection  with  the  acute  rheumatism  of  childhood.  See  the 
Lancet,  January  6,  1906,  p.  29. 

^  For  description  of  which  see  Dr.  J.  W.  Ogle  in  Trans,  of  Pathol. 
Soc.  oj  London.,  vol.  xiv.,  p.  127,  1863.  See  also  Dr.  Wickham  Legg, 
ibid.^  vol.  xxix.,  p.  49,  1877,  and  St.  George's  Hospital  Museum, 
Series  vi.,  47/. 


1 6  Phlebitis  and  Thrombosis 

seen  in  the  course  of  syphilis  and  other  infective  diseases, 
and  is  occasionally  met  with  in  cases  of  anaemia  and 
wasting  diseases,  in  which  no  changes  in  the  arterial  walls 
can  be  detected.  In  wounds  and  injuries  of  arteries  the 
resulting  thrombus  is  caused  partly  by  mechanical  obstruc- 
tion to  the  blood-stream  owing  to  the  projection  into  the 
lumen  of  the  inner  coat,  and  partly  in  consequence  of  the 
interference  with  the  normal  influence  of  the  intima.  The 
same  may  be  said  of  the  application  of  a  ligature.  In  the 
case  also  of  atheromatous  and  other  degenerations  of  the 
arterial  coats,  and  in  aneurisms,  the  destruction  of  the 
intima  and  the  roughening  of  the  inner  surface  of 
the  vessel  are  largely  concerned  in  the  deposition  of  mural 
clot,  but  some  retardation  or  irregularity  in  the  blood- 
current  seems  to  be  also  necessary. 

In  obliterating  arteritis  the  obstruction  of  the  vessel, 
though  partly  due  to  the  arterial  sclerosis,  is  also  (as  has 
been  shown  by  Zoege-Manteuffel)  ^  largely  produced  by 
the  deposition  and  organization  of  blood-clot.  No  doubt 
this  condition  is  frequently  due  to  syphilis,  but  it  also 
occurs  in  the  course  of  other  infective  diseases,  as  the 
specific  fevers,  rheumatism,  influenza,  and  pneumonia. 
Rare  instances  are  also  recorded  of  arterial  thrombosis  in 
connection  with  phthisis,  and  Professor  Welch  ^  describes 
a  specimen  showing  a  tubercular  focus  in  the  intima  of 
the  aorta,  on  which  a  thrombus  has  formed  containing 
tubercle  bacilli. 

Besides  these  changes  in  the  arterial  wall,  certain  con- 
ditions of  the  blood,  in  combination  with  a  slow  and 
feeble  circulation,  will  lead  to  coagulation  in  the  arteries  ; 
as  is  seen  in  chlorosis,  anaemia,  and  towards  the  end  of 

^  W.  Zoege-Manteuffel  :    Deut.   Zeit.   f.    Chir.,  1898,    vol.    xlvii., 
p.  461. 
2  Allbutt's  '  System  of  Medicine,'  vol.  vi.,  p.  196,  1899. 


^,=**'S»*'^ 


FIG.    3. — SECTION    OF     BRANCH     OF     FEMORAL    ARTERY    FROM    A   WOMAN,    AGED 

TWENTY-THREE  YEARS,  WHO    DIED    FROM    EXTENSIVE   THROMBOSIS    OF   THE 

PULMONARY    ARTERY:    THE   ARTERY    FULL   OF    CLOT;    COATS    NATURAL. 


[  To  face  />.  17. 


Phlebitis  and  Thrombosis  17 

exhausting  diseases,  but  this  is  much  less  common  in  the 
arteries  than  in  the  veins. 

Such  a  condition  is  illustrated  by  a  specimen  in  the 
museum  of  St.  George's  Hospital  (Series  VI.,  6id),  taken 
from  the  body  of  a  woman  aged  thirty-seven  years,  who 
died  from  gangrene  of  the  lower  limbs.  The  specimen 
shows  part  of  the  aorta  and  the  iliac  arteries  filled  with 
old  coagula  adherent  to  the  internal  coat  of  the  artery,  but 
the  coats  of  the  vessel  are  not  thickened  (Fig.  2).  The 
general  tendency  to  thrombosis  is  shown  by  the  fact  that 
similar  coagula  were  found  in  the  main  arterial  trunks  and 
in  the  veins  of  both  lower  limbs,  in  the  iliac  veins  and  lower 
part  of  the  vena  cava,  in  the  arteries  and  veins  of  the  left 
kidney,  and  in  the  left  ventricle  and  right  auricle  of  the 
heart.     A  specimen  from  a  similar  case  is  shown  in  Fig.  3. 

Thrombosis  of  arteries  has  been  observed  in  connection 
with  various  acute  diseases,  especially  influenza,  enteric 
fever,  typhus  fever,  and  pneumonia.  Here  again  it  is 
much  less  common  than  in  the  veins,  and  is  found  chiefly 
in  the  arteries  of  the  lower  extremities. 

Cases  have  also  been  recorded  by  Dr.  Dickinson^  of 
death  from  rapid  thrombosis  of  cerebral  arteries  in  which 
there  was  no  disease  of  the  vessels  and  no  acute  illness. 

*  It  appears,'  says  Dr.  Dickinson,  *  that  in  most  of  these 
cases  two  influences  have  been  in  operation.  There  has 
been  disease  of  the  heart,  particularly  contraction  of  the 
mitral  opening.  This  occurred  in  four  of  the  five  cases. 
The  general  circulation  has  thus  lost  freedom,  and  a 
liability  to  venous  and  capillary  congestion  has  been 
established.  Besides  this,  there  has  been  some  especial 
cause  by  which  the  cerebral  vessels  have  been  overloaded 
or  the  circulation  in  them  disturbed.' 

^  SL  George's  Hospital  Reports^  vol.  i.,  1886,  p.  257. 

2 


iS  Phlebitis  and  Thrombosis 

Mr.  Jonathan  Hutchinson^  has  also  recorded  instances 
of  the  sudden  occlusion  of  the  femoral  and  other  large 
arteries  by  thrombosis,  in  which  he  could  discover  no 
evidence  of  disease  of  the  vessels. 

Professor  Osier  ^  has  related  a  remarkable  case  of  a 
labourer,  aged  twenty,  who  was  attacked  with  diarrhoea, 
loss  of  appetite,  and  epistaxis,  followed  by  abdominal 
pain,  fever,  and  delirium.  Beneath  the  skin  of  the 
anterior  thoracic  region  and  the  abdomen  were  many 
localized  blue  spots,  but  no  characteristic  eruption.  On 
the  tenth  day  of  the  illness  symptoms  of  gangrene  of  the 
lower  limbs  appeared ;  the  pulse  was  120  to  140  ;  tempera- 
ture, 101°  to  103°;  there  was  great  restlessness,  persistent 
delirium,  and  abdominal  tenderness.  No  pulsation  could 
be  felt  in  the  femoral  or  popliteal  arteries.  The  blood  was 
examined  with  negative  result ;  the  urine  was  scanty  and 
albuminous.  The  man  died  about  two  weeks  from  the 
beginning  of  his  illness. 

The  case  was  regarded  as  one  of  typhoid  fever,  but  the 
autopsy  negatived  this  :  the  ileum  was  normal.  There 
was  thrombosis  of  the  lower  two  inches  of  the  abdominal 
aorta,  with  plugging  of  iliacs  and  femorals,  the  clots  firm, 
reddish-brown,  and  closely  adherent.  The  mesenteric 
vessels  were  free,  but  two  large  branches  of  the  splenic 
artery  were  plugged.  There  were  infarcts  in  the  right 
kidney  and  spleen,  from  the  latter  of  which  spread  a 
general  peritonitis.  Heart,  lungs,  and  brain  were  normal. 
No  otitis,  no  bone  lesions.  No  micro-organisms  were 
found  in  the  blood  during  life.  After  death  numerous 
micrococci  were  found  in  the  infarct  of  the  spleen  and  the 
lymph  covering  it. 

In  septic  conditions  it  has  been  observed  that  the  blood- 
platelets  are  abnormally  numerous,  and  a  primary  arterial 

^  Archives  of  Surgery,  vol.  vii.,  p.  29,  and  vol  ix.,  p.  100. 

2  Transactions  of  Association  of  America7i  Physicians,  1887,  p.  135. 


Phlebitis  and  Thrombosis  19 

thrombosis  may  occur,  to  which  the  infection  of  the 
vascular  wall  is  secondary. 

Arterial  thromxbosis  occurs  most  frequently  in  the  lower 
limbs,  but  does  not  exhibit  the  preference  shown  by  the 
veins  for  the  left  side. 

The  symptoms  are  chiefly  those  due  to  obstruction  of 
the  vessel,  and  will  depend  very  much  upon  whether  this 
takes  place  rapidly  or  slowly,  and  also  upon  the  position 
and  importance  of  the  artery  concerned.  When  the 
artery  is  rapidly  blocked  the  symptoms  resemble  those  of 
embolism,  from  which  it  is  often  impossible  to  distinguish 
them.  When  the  thrombus  is  of  gradual  formation  there 
may  be  sufficient  opportunity  for  the  development  of  a 
collateral  circulation  to  prevent  any  serious  results,  though 
this  will,  of  course,  depend  upon  the  condition  of  the 
arteries  generally,  and  their  capacity  to  respond  to  the 
call  upon  their  development. 

The  gradual  obliteration  of  an  artery  may  only  be 
recognisable  by  the  increasing  hardness  and  thickness  of 
the  vessel,  its  want  of  elasticity,  and  the  feebleness  of  its 
pulsation.  There  is  often,  however,  some  pain  and 
tenderness  felt  in  the  course  of  the  artery.  When  more 
rapid  arterial  thrombosis  occurs  there  is  usually  acute 
pain,  and  the  artery  is  tender  to  pressure ;  the  nutrition 
of  the  limb  is  seriously  imperilled,  and,  as  in  embolism, 
unless  a  collateral  circulation  is  soon  established,  gangrene 
results.  The  danger  of  gangrene  is  less  in  the  upper  than 
in  the  lower  extremities,  but  is  greatly  increased  if  the 
veins  are  also  thrombosed,  as  in  the  case  quoted  on  p.  17. 

Rapid  obstruction  of  visceral  and  cerebral  arteries  is 
most  often  of  embolic  origin,  although  it  may  sometimes 
be  due  to  thrombosis. ^     Dr.  W.  H.  Brown  has  recorded  a 

1  See  Dr.  Dickinson's  cases,  S/.  George^ s  Hospital  Eeports^  vol.  i., 
p.  257. 

2 — 2 


20  Phlebitis  and  Thrombosis 

case  of  thrombosis  of  the  abdominal  aorta,  iHac  and 
femoral  arteries,  in  which  gangrene  of  the  intestine 
occurred  probably,  I  suppose,  from  thrombosis  of  the 
mesenteric  artery.^ 

Obstruction  of  the  coronary  arteries  is  commonly  due  to 
a  combination  of  arterial  degeneration  and  thrombosis,  the 
sudden  development  of  symptoms  (as,  e.g.,  angina  pectoris) 
depending  upon  the  completion  of  obstruction  by  throm- 
bus of  a  vessel  already  narrowed  by  thickening  of  its 
coats. 

Thrombosis  of  the  pulmonary  arteries  will  be  con- 
sidered in  connection  with  venous  thrombosis  and 
pulmonary  embolism. 

Senile  gangrene  is  usually  caused  by  thrombosis  of  the 
small  terminal  arteries,  the  first  symptom  of  which  is 
often  acute  pain.  Doubtless  arterio-sclerosis  and  feeble 
circulation  play  an  important  part  in  its  production,  and 
the  mischief  is  often  started  by  some  slight  injury  or 
inflammation,  but  the  thrombosis  is  the  immediate 
cause.  ^  It  is  important  to  recognise  this  because,  if 
the  condition  is  seen  and  appreciated  at  its  commence- 
ment, the  danger  may  be  averted  by  appropriate  treat- 
ment. The  reason  why  thrombosis  is  not  more  common 
in  connection  with  arterio-sclerosis  is  that  the  heart  is 
usually  hypertrophied,  so  that  the  arterial  resistance  is 
overcome  by  the  increased  heart  power. 

Venous  Thrombosis. 

The  conditions  under  which  coagulation  of  the  blood 
occurs  in  the  living  veins  are  very  similar  to  those  which 

^  Transactions  of  Clinical  Society  of  Londofi,  vol.  xxvi.,  p.  i. 

2  Diabetic  gangrene  is  probably  caused  by  the  same  conditions. 
See  remarks  by^M.  Barthdlemy  at  the  Fifth  International  Dermato- 
logical  Congress  {^Transactions,  vol.  ii.,  part  i.  p.  252). 


Phlebitis  and  Thrombosis  21 

lead   to   the   formation    of    coagula  in   the   arteries,  but 
venous  thrombosis  is  more  common  than  arterial. 

It  has  already  been  pointed  out  that  any  impairment 
of  the  nutrition  of  the  endothelium  of  the  bloodvessels 
leads  to  the  formation  of  thrombi  upon  the  vessel  wall, 
and  such  an  impairment  of  nutrition  occurs  whenever  the 
rapidity  of  the  circulation  is  materially  diminished  for 
any  length  of  time.  '  This,'  as  pointed  out  by  Dr.  Lazarus- 
Barlow,^  '  depends  upon  the  fact  that  the  intima,  in- 
cluding the  endothelial  cells,  unlike  the  rest  of  the  vessel 
wall,  derives  its  nutriment  from  the  blood  in  the  lumen  of 
the  vessel,  and  not  from  that  conveyed  by  the  vasa  vasorum. 
In  most  cases  a  diminution  in  velocity  of  blood-flow  is  the 
proximate  cause  of  the  thrombosis.  Thus,  in  the  heart 
the  circulation  is  slowest  in  the  appendices  auriculae, 
behind  the  flaps  of  the  auriculo-ventricular  valves,  and 
between  the  columnse  carneas.  Normally  it  is  rapid 
enough  even  here  to  maintain  the  nutrition  of  the  cardiac 
endothelium  ;  but  when  old  age  or  wasting  disease  or  any 
lesion  of  the  valves  has  impaired  the  musculature  of  the 
heart,  and  it  is  no  longer  able  to  maintain  the  circulation 
at  its  normal  velocity,  the  endothelium  in  these  situations 
suffers  first  and  to  the  greatest  extent,  and  it  is  just  in 
these  situations  that  thrombi  are  found.  For  the  same 
reason  thrombosis  more  commonly  occurs  in  veins  than 
in  arteries.' 

In  wounds,  injuries,  and  ligature  of  veins,  coagulation 
of  the  blood  occurs,  partly  as  a  consequence  of  the 
mechanical  disturbance  of  the  blood -flow,  and  partly 
from  the  interference  with  the  integrity  of  the  endo- 
thelium. It  occurs  more  readily  than  in  wounds  of 
arteries,   because  of  the   slower  and  less  forcible  blood- 

^  'A  Manual  of  General  and  Experimental  Pathology,'  by  W.  S 
Lazarus- Barlow,  1904,  p.  117. 


22  Phlebitis  and  Thrombosis 

stream,  and  perhaps  also  because  of  the  greater  coagula- 
bility of  the  venous  blood. ^ 

Degeneration  of  the  venous  walls,  dilatations,  varices, 
and  anything  producing  obstruction  or  retardation  of 
the  blood-current,  are  causes  of  thrombosis  by  disturbing 
the  normal  relations  between  the  blood  and  the  venous 
endothelium. 

Inflammation  of  veins  is  a  common  cause  of  thrombosis, 
and,  owing  to  the  thinness  of  the  venous  coats,  any  sur- 
rounding inflammation  invading  the  outer  tunic  of  the 
vein  is  easily  conveyed  to  the  endothelium.  This  is  one 
reason  for  the  greater  frequency  of  venous  as  compared 
with  arterial  thrombosis.  The  presence  of  micro- 
organisms either  in  the  blood  or  the  venous  wall  will 
give  rise  to  thrombosis,  as  is  frequently  seen  in  septic 
inflammations.  Venous  thrombosis  also  occurs  in  con- 
sequence of  changes  in  the  blood  ;  in  connection  with 
various  acute  and  chronic  diseases ;  and  in  conditions 
of  great  debility. 

When  coagulation  occurs  in  a  living  vein,  it  is  often 
difficult  to  say  whether  the  thrombus  is  the  cause  or  the 
result  of  phlebitis.  If  a  vein  is  obstructed  by  a  thrombus 
the  nutrition  of  the  endothelium  at  once  suffers,  and  if 
the  clot  contains  micro-organisms  they  will  soon  invade 
the  intima,  the  resistance  of  which  will  be  already 
lowered,  and  an  endophlebitis  will  ensue. 

But,  on  the  other  hand,  there  are  numerous  cases 
in  which  it  is  certain  that  the  changes  in  the  vein  precede 
the  thrombosis ;  for  instance,  in  the  chronic  inflamma- 
tion which  occurs  in  connection  with  varix,  in  syphilitic 
endophlebitis,  in  tubercular  invasion  of  the  vein,  and  in 

1  Wooldridge  has  shown  that  the  plasma  of  peptonized  blood,  which 
does  not  coagulate  on  the  addition  of  fibrin  ferment,  coagulates  freely 
if  in  addition  a  stream  of  carbonic  acid  is  passed  through  it.  ('  The 
Chemistry  of  the  Blood,'  p.  294.) 


FIG.    4.  —  FEMORAL    VEIN    FROM    A    CASE   OF    INFECTIVE    PHLEBITIS  :    SHOWING 
GREAT   THICKENING    OF    COATS    OF    VEIN    AND    DISINTEGRATING    CLOT. 


[  To  face  p.  23. 


Phlebitis  and  Thrombosis  23 

other  degenerative  changes.  So  also  in  septic  inflam- 
mation spreading  to  the  outer  coat  of  a  vein  from  a 
neighbouring  focus,  invasion  takes  place  from  v^ithout 
inv^ards,  and  thrombosis  does  not  occur  till  the  intima  is 
reached. 

The  most  serious  of  these  conditions  are  those  of  septic 
origin.  Here  the  presence  of  micro-organisms  gives  rise 
to  coagulation,  and  the  clot  has  an  infective  character 
which  it  communicates  to  any  part  to  which  it  is  carried. 
The  process  may  begin  in  inflammation  of  the  outer  coat 
of  a  vein  originating  in  a  septic  or  suppurating  wound,  or 
in  an  infective  focus,  as  in  middle-ear  disease  or  acute 
necrosis  of  bone ;  this,  spreading  to  the  inner  coats,  leads 
to  endophlebitis  and  consequent  thrombosis ;  or  the 
organisms  may  invade  the  intima  from  the  circulating 
blood  or  from  an  infected  thrombus  brought  from  a 
distant  part.  In  these  septic  cases,  whichever  the  mode 
of  origin,  the  coats  of  the  vein  are  always  found  much 
thickened  (Fig.  4). 

Phlegmasia  dolens  is  an  example  of  septic  phlebitis  ex- 
tending from  the  uterine  veins,  through  the  iliacs,  to  the 
femoral  and  other  veins.  Thrombosis  beginning  in  the 
uterine  veins  may  extend  from  the  uterus  to  the  iliac  and 
femoral  veins,  and  even  to  the  vena  cava.  Sometimes, 
however,  the  phlebitis  would  appear  to.  be  the  result  of 
the  transmission  of  infecting  organisms  by  the  blood,  and 
not  of  direct  extension  from  the  uterus. 

There  is  an  admirable  paper  on  phlegmasia  dolens,  by 
Dr.  David  D.  Davis,  in  the  Transactions  of  the  Royal 
Medical  and  Chirurgical  Society  for  1823,^  in  which  the 
author  describes  several  cases  of  the  affection,  and  proves 
by  dissection  that  its  proximate  cause  is  an  inflammation 

1  Transactions  of  the  Royal  Medical  and  Chirurgical  Society, 
vol.  xii.,  p.  419,  1823. 


24  Phlebitis  and  Thrombosis 

and  obstruction  of  '  one  or  more  of  the  principal  veins 
within  and  in  the  immediate  neighbourhood  of  the  pelvis.' 
But  he  did  not  trace  the  disease  of  the  veins  to  its  source 
in  the  uterus,  though  he  recognised  its  connection  with 
parturition  and  with  disease  of  the  pelvic  organs.^  The 
paper  is  illustrated  by  beautiful  coloured  drawings  show- 
ing the  condition  of  the  iliac  veins  and  the  contained 
clot. 

Dr.  Robert  Lee^  in  the  year  1829  contributed  two 
papers,  with  excellent  coloured  illustrations,  to  the  same 
Society,  in  which  he  reported  thirteen  cases  of  phlegmasia 
dolens,  in  six  of  which  the  actual  condition  of  the  iliac 
and  femoral  veins  was  ascertained  by  dissection.  '  From 
this  I  was  led  to  infer,'  says  Dr.  Lee,  '  that  inflammation 
of  the  iliac  and  femoral  veins  gives  rise  to  all  the  pheno- 
mena of  that  disease  in  puerperal  women,  and  that  in 
phlegmasia  dolens  the  inflammation  commences  in  the 
uterine  branches  of  the  hypogastric  veins,  and  subse- 
quently extends  from  them  into  the  iliac  and  femoral 
trunks  of  the  affected  side.'^ 

In  the  second  paper  Dr.  Lee^  reported  three  cases  of 
cancerous  ulceration  of  the  uterus  in  which  there  was 
inflammation  of  the  internal,  common,  and  external  iliac 
and  femoral  veins,  with  all  the  characteristic  symptoms  of 
puerperal  phlegmasia  dolens. 

In  a  third  paper,  published  in  1853,^  Dr.  Lee  reported 
forty-three  additional  cases  in  confirmation  of  his  ex- 
planation of  the  pathology  of  the  disease,  and  he  adds 
that  it  has  been  demonstrated  by  morbid  anatomy  that 
phlegmasia  dolens  is  a  disease  which  may  take  place  in 
women  who  have  never  been  pregnant,  and  in  the  male 

^  Transactions   of  the   Royal   Medical  and    Chirurgical    Society, 
vol.  xii.,  p.  445. 
2  Ibid.,  vol.  XV.,  p.  132,  and  p.  369.  ^  Ibid.,  vol.  xxxvi.,  p.  281. 

^  Ibid.,  vol.  XV.,  p.  369.  ^  Ibid.,  vol.  xxxvi.,  p.  281. 


Phlebitis  and  Thrombosis  25 

sex,  and  that  under  all  circumstances  the  proximate  cause 
is  the  same — namely,  inflammation  of  the  iliac  and  femoral 
veins. 

In  the  same  volume  of  transactions  is  an  elaborate 
paper  by  Dr.  F.  W.  Mackenzie,^  containing  '  Researches 
on  the  Pathology  of  Obstructive  Phlebitis,  and  the  Nature 
and  Proximate  Cause  of  Phlegmasia  Dolens,'  and  record- 
ing a  number  of  experiments  on  animals  made  with  the  view 
of  studying  the  effects  of  inflammation  of  the  iliac  veins. 
From  these  experiments  Dr.  Mackenzie  concluded  that  in 
a  healthy  animal  the  results  of  obstruction  of  the  common 
iliac  vein,  produced  by  the  application  of  a  ligature  or 
other  irritants,  were  confined  to  the  immediate  seat  of 
injury,  and  showed  no  tendency  to  spread  beyond  it. 
There  was  no  attendant  fever  or  constitutional  disturb- 
ance, and  only  a  slight  and  transient  oedema  of  the  limb. 
But,  on  the  other  hand.  Dr.  Mackenzie  ascertained  by 
another  series  of  experiments,  that  if  the  blood  was 
vitiated  from  local  or  constitutional  causes,  large  portions 
of  the  venous  system  may  become  obstructed  and  inflamed 
independently  of  any  injury  of  the  veins  ;  and  he  assumed 
that  these  phenomena  depended  upon  '  a  disturbance  of 
the  relations  which  normally  exist  between  the  blood  and 
the  lining  membrane  of  the  veins.'  Finally,  applying  the 
results  of  his  experiments  upon  animals  to  an  analysis  of 
TOO  cases  of  phlegmasia  dolens  in  the  human  subject,  he 
concluded  that  the  obstruction  and  inflammation  of  the 
iliac  and  crural  veins,  which  is  an  essential  feature  of  the 
disease,  depends  upon  the  presence  of  abnormal  material 
in  the  blood.^ 

Here,  it  will  be  observed,  was  a  very  close  approach  to 

^   Transactions    of   the   Royal  Medical  and   Chirurgical    Society, 
vol.  xxxvi.,  p.  169. 

^  Ibid.,  vol.  xxxvi.,  p.  240. 


26  Phlebitis  and  Thrombosis 

the  recognition  of  a  microbic  origin  for  the  disease ;  and 
it  may  be  noticed  that  the  important  and  accurate  advance 
in  the  knowledge  of  the  causation  of  phlegmasia  dolens, 
made  by  the  three  authors  to  whose  work  I  have  drawn 
attention,  was  the  result  of  laborious  pathological  investi- 
gation, of  experiments  upon  animals,  and  of  careful 
clinical  observation — a  striking  contrast  to  the  wild  and 
unfounded  theories  which  had  previously  prevailed. 

Pylephlebitis  is  an  example  of  suppurative  inflammation 
and  thrombosis  of  the  portal  vein,  originating  in  an  in- 
fective focus  in  some  part  of  the  area  belonging  to  the 
branches  of  the  vein.  The  most  common  origin  is  sup- 
puration in  connection  with  the  vermiform  appendix,  a 
point  to  be  borne  in  mind  in  relation  both  to  the  diagnosis 
and  treatment.  The  symptoms  are  often  obscure,  but 
are  chiefly  suggestive  of  pyaemia.  Rigors,  fever  of  the 
remittent  type,  sweating,  jaundice,  and  enlargement  and 
tenderness  of  the  liver,  would  make  the  diagnosis  probable, 
especially  if  there  were  evidence  of  intestinal  disease,  for 
which  a  careful  search  should  be  made. 

In  the  light  of  recent  investigations  it  seems  probable 
that  many  of  the  so-called  idiopathic  or  spontaneous 
thromboses  are  of  microbic  origin ;  but  there  are  some  in 
which  no  micro-organisms  can  be  found  in  the  thrombi : 
while,  on  the  other  hand,  bacterial  invasion  of  the  wall  of 
a  vein  may  occur  without  the  formation  of  a  thrombus. 

Septic  phlebitis  is  a  condition  attended  by  serious 
symptoms  and  grave  danger.  The  severity  of  the 
symptoms  will  depend  upon  the  virulence  of  the  infection, 
the  susceptibility  of  the  individual,  and  the  position  of  the 
mischief. 

In  the  acute  form  of  suppurative  phlebitis  the  wall  of 
the  vein  is  invaded  by  pyogenic  organisms  ;  coagulation 
occurs  in  the  inflamed  vein,  and  the  thrombus  is  itself 


Phlebitis  and  Thrombosis  27 

infected,  and  by  its  softening  carries  infection  into  the 
blood-stream,  giving  rise  to  septicaemia  and  pyaemia.  An 
admirable  paper  on  this  subject  was  communicated  by 
Mr.  Arnott  to  the  Royal  Medical  and  Chirurgical  Society 
in  1828,  in  which  he  showed  the  relation  between  the 
primary  and  secondary  affections  in  phlebitis.^ 

If  a  superficial  vein  is  affected  it  is  observed  to  be  swollen 
and  tender,  and  the  skin  over  it  shows  a  red  line.  These 
conditions  tend  to  spread  rapidly  along  the  vein  in  the 
direction  of  the  blood-stream.  If  a  deep  vein  is  attacked 
pain  is  felt  in  the  part,  soon  followed  by  swelling,  tender- 
ness and  suppuration.  The  constitutional  symptoms  are 
severe ;  the  temperature  and  pulse  rise  rapidly ;  rigors 
supervene,  followed  by  profuse  sweating  ;  the  tongue  is 
dry,  appetite  is  lost,  and  there  may  be  delirium.  To 
these  symptoms  are  soon  added  those  of  general  pyaemia  : 
rapid  oscillations  of  temperature,  rigors,  sweating,  and 
disseminated  suppurations.  Such  cases  usually  end 
fatally,  partly  by  the  general  poisoning  of  the  blood  and 
the  consequent  fever  and  exhaustion,  and  partly  by  the 
occurrence  in  important  organs,  especially  the  lungs,  of 
centres  of  inflammation  and  suppuration. 

Chaucer  described  the  condition  very  accurately  in  the 
'  Knighte's  Tale.' 

'  The  clothred  blood,  for  eny  leche-craft, 
Corrumpith,  and  is  in  his  bouk  i-laft, 
That  nother  veyne  blood,  ne  ventusyng, 
Ne  drink  of  herbes  may  ben  his  helpyng. 
The  vertu  expulsif,  or  animal, 
Fro  thilke  vertu  cleped  natural, 
Ne  may  the  venym  voyde,  ne  expelle. 
The  pypes  of  his  lounges  gan  to  swelle, 
And  every  lacerte  in  his  brest  adoun 
Is  shent  with  venym  and  corrupcion. 

^  Transactions  of  the  Royal  Medical  and  Chirurgical  Society, 
vol.  XV.,  p.  I. 


28  Phlebitis  and  Thrombosis 

Him  gayneth  nother,  for  to  get  his  lyf, 

Vomyt  up-ward,  ne  doun-ward  laxatif  ; 

Al  is  to-broken  thilke  regioun  ; 

Nature  hath  now  no  dominacioun. 

And  certeynly  wher  natur  will  not  wirche, 

Farwel  phisik  ;  go  here  the  man  to  chirche.' 

When  the  infection  is  less  virulent  the  symptoms  are 
correspondingly  less  severe;  and  many  gradations  are  met 
with  down  to  cases  in  which,  though  there  is  a  well- 
marked  phlebitis,  the  symptoms  of  infection  are  but 
slight.  I  have  no  doubt  that  some  of  the  cases  of  so- 
called  idiopathic  phlebitis  are  of  this  nature.  The 
infection  may  be  of  a  low  degree  of  virulence,  and  the 
subject  may  have  a  high  resisting  power  or  immunity. 
Moreover,  the  infected  thrombus  may  be  isolated  from 
the  general  circulation,  and  so  produce  only  local  effects. 

In  other  cases  the  phlebitis  may  become  manifest,  while 
the  source  of  the  infection  may  be  obscure.  For  instance, 
I  have  seen  a  case  in  which  a  slowly-forming  ischio-rectal 
abscess,  accompanied  by  so  little  pain  that  the  patient 
disregarded  it,  gave  rise  to  a  septic  phlebitis,  manifested 
by  rigors,  fever  and  sweating,  as  well  as  by  severe  local 
symptoms. 

In  some  of  the  cases  of  chronic  pyaemia  in  which  large 
superficial  collections  of  pus  occur  I  have  found  indubit- 
able evidence  of  thrombosis,  and  on  opening  the  abscesses 
the  pus  was  seen  to  be  mixed  with  broken-down  blood- 
clot. 

In  all  cases  of  phlebitis  it  is  therefore  well  to  seek  for 
a  source  of  infection,  for  in  many  instances  in  which  the 
disease  begins  with  but  slight  constitutional  disturbance 
symptoms  of  severe  infection  subsequently  develop. 
These  symptoms  probably  arise  coincidently  with  the 
disintegration  of  the  infected  thrombus  and  the  entrance 
into  the  blood-stream  of  septic  organisms.    The  successful 


Phlebitis  and  Thrombosis  29 

treatment  of  such  cases  will,  of  course,  depend  very 
largely  upon  the  removal  of  the  focus  of  infection. 
Notable  examples  of  this  are  the  cases  of  chronic  sup- 
puration of  the  middle  ear  giving  rise  to  endophlebitis 
and  purulent  thrombosis  of  the  lateral  sinus,  in  which  life 
may  be  saved  by  ligature  of  the  internal  jugular  vein,  and 
the  thorough  removal  from  the  sinus  of  the  infected  clot. 

In  other  cases  of  phlebitis  the  focus  of  infection  may 
be  found  in  a  deeply-seated  abscess,  a  suppurating  wound, 
or  an  osteomyelitis,  and  the  first  essential  in  the  treat- 
ment is  the  removal  or  disinfection  of  such  focus. 
Abscesses  must  be  freely  opened  and  thoroughly  cleansed 
and  drained  ;  suppurating  or  foul  wounds  must  be  disin- 
fected; bones  the  subject  of  osteomyelitis  must  be 
removed  by  resection  or  amputation  ;  an  accessible  vein 
suspected  to  contain  a  septic  clot  should  be  ligatured 
above  and  below  the  thrombus,  and  the  portion  between 
the  ligatures  excised.  Beyond  these  local  measures  the 
treatment  must  be  adapted  to  the  general  condition  of 
the  patient.  In  the  severe  and  advanced  cases  it  will 
be  that  of  pyaemia.  Quinine  should  be  given  in  frequently 
repeated  doses,  and  the  strength  supported  by  appropriate 
food  and  stimulants.  The  exclusion  of  all  insanitary 
conditions  should  be  carefully  looked  to,  and  the  patient 
should  be  kept  in  a  well-ventilated  and  light  room,  and 
removed  as  soon  as  possible  into  fresh  and  healthy 
surroundings.     He  should  not  remain 

'  in  populous  city  pent, 
Where  houses  thick  and  sewers  annoy  the  air';^ 

but  should  seek 

'  airs,  vernal  airs 
Breathing  the  smell  of  field  and  grove.''^ 

^  Milton,  'Paradise  Lost,'  ix.  445. 
^  Ibid.^  iv.  264. 


30  Phlebitis  and  Thrombosis 

He  should  go  where  he  can 

'  look  into  the  fair 
And  open  face  of  heaven. '^ 

For  pure  air  and  sunshine  are  valuable  aids  to  recovery, 
and  the  high  moorlands  are  often  more  beneficial  than 
the  sea-coast. 

^  Keats,  '  Sonnets,'  x. 


LECTURE  II 

Varieties  of  phlebitis  and  thrombosis. — Thrombosis  in  connection 
with  {a)  varix  ;  {b)  gout  ;  {c)  syphilis  ;  {d)  enteric  fever  ;  {e)  typhus 
fever  ;  (/)  chlorosis  ;  {g)  influenza ;  {h)  pneumonia  ;  {i)  appendicitis  ; 
{j)  gastric  ulcer  and  other  abdominal  diseases. — '  Idiopathic  '  throm 
bosis. — Preference  of  venous  thrombosis  for  left  lower  limb. 

Thrombosis  of  upper  limb. 

Pulmonary  embolism  and  thrombosis. 

Symptoms  of  non-infective  phlebitis  and  thrombosis. — Explanation  of 
occurrence  or  absence  of  oedema. — Results  of  venous  obstruction 
and  obliteration. — Obliteration  of  vente  cava;. 

Leaving  now  the  cases  of  undoubted  septic  origin,  we 
come  to  the  consideration  of  a  class  in  which  the  phlebitis 
is  of  quite  different  character,  and  of  which  the  dangers 
are  of  a  quite  different  kind. 

Many  of  these  undoubtedly  depend  upon  changes  in 
the  blood  which  favour  the  occurrence  of  thrombosis,  to 
which  the  phlebitis  is  secondary. 

It  seems  possible  that  in  some  of  the  diseases  with 
which  venous  thrombosis  is  associated,  toxic  or  other 
chemical  changes  in  the  blood  may  affect  the  nutrition 
of  the  leucocytes  and  red  corpuscles,  or  favour  the  pro- 
duction and  increase  of  the  blood-plates,  and  thus,  aided 
by  an  enfeebled  circulation,  lead  to  the  formation  of  a 
thrombus. 

Professor  Osier ^  has  observed  that  in  acute  fevers  the 

■^  Osier,  '  Cartwright  Lectures,'  op.  at.,  p.  365. 
31 


32  Phlebitis  and  Thrombosis 

blood-plates  do  not  become  more  numerous  in  the  early- 
stage  of  the  disease,  but  increase  in  number  as  the  patient 
becomes  weaker  and  more  debilitated.  In  typhoid  fever, 
for  instance,  there  is  no  increase  during  the  first  week, 
but  a  notable  increase  in  the  third  and  fourth  weeks. 

It  will  be  observed  that  the  increase  in  the  number 
of  the  blood-plates  occurs  just  in  that  stage  of  disease 
which  is  especially  liable  to  thrombosis. 

Dr.  J.  H.  Pratt/  of  Boston,  has  reported  a  series  of 
observations  on  the  relative  number  of  the  platelets  in 
various  diseases.  There  was  a  marked  increase  in 
chlorosis  ;  the  greatest  diminution  was  observed  in  a  case 
of  purpura  hemorrhagica. 

In  other  cases  in  which  the  slowness  or  feebleness  of 
the  circulation  would  seem  to  be  the  chief  factor,  it  is 
difficult  to  say  how  far  the  diminished  nutrition  of  the 
vessel  wall  is  the  immediate  cause  of  coagulation,  and  how 
much  is  due  to  the  invasion  of  micro-organisms. 

Mr.  W.  C.  C.  Pakes^  has  recorded  the  case  of  an 
anaemic  and  phthisical  girl  of  thirteen  years  who  was 
admitted  to  Guy's  Hospital  with  thrombosis  of  the  left 
iliac  vein  and  swelling  of  the  left  lower  limb.  A  week 
before  death  the  right  leg  became  swollen,  owing  to 
thrombosis  of  the  right  iliac  vein.  Post-mortem  there 
were  thrombi  in  both  iliac  and  femoral  veins  ;  and  in  the 
thrombus  of  the  left  femoral  vein,  which  was  carefully 
excised  and  examined,  was  found  the  Bacillus  proteus 
vulgaris. 

Mr.  Pakes  remarks  that  '  in  health  the  bactericidal 
power  of  the  blood  is  probably  sufficiently  great  to 
destroy  this  organism  if  it  should  gain  access  to  it ;  but 
when     from    any    cause   this    action    is    diminished,    the 

■'■  Johjts  Hopkms  Hospital  Bulletin.,  May,  1905,  p.  201. 

2  Transactions  of  Pathological  Society  of  London^  vol.  li.,  p.  47. 


Phlebitis  and  Thrombosis  33 

organism  becomes  relatively  pathogenic.  The  bacteri- 
cidal power  may  be  reduced  in  many  ways,  of  which  a 
wasting  disease  and  a  dose  of  ptomaines  are  two.' 

Dr.  F.  C.  Turner^  has  published  a  case  of  thrombosis 
of  the  iliac  vein  in  a  man,  aged  thirty-six,  who  died  of 
Hodgkin's  disease,  a  condition  in  which  there  are  im- 
portant changes  in  the  leucocytes,  possibly  due  to  micro- 
organisms. 

Thrombosis  is  a  common  occurrence  in  varicose  veins, 
and  is  usually  the  result  of  injury ;  but  in  gouty  persons 
the  subject  of  varix  it  is  often  seen  in  association  with 
eczema,  when  no  injury  can  be  traced. 

Coagulation  is  especially  apt  to  occur  in  the  cyst-like 
dilatations  and  tortuous  veins  so  frequently  met  with  in  the 
lower  part  of  the  thigh  and  the  neighbourhood  of  the 
knee.  Such  varices  are  very  liable  to  become  inflamed 
because  of  their  prominence  on  a  part  of  the  limb  often 
exposed  to  injury,  and  because  in  this  situation  they  are 
particularly  subject  to  irritation  from  pressure  and  fric- 
tion, as  in  riding  and  other  exercises. 

In  varicocele  also  thrombosis  is  not  infrequently  caused 
by  injury,  and  in  some  cases  the  resulting  obliteration  of 
the  veins  produces  a  complete  cure  of  the  varicocele. 

In  gouty  persons  it  is  more  often  the  smaller  nasvus-like 
patches  of  varicose  veins  in  the  lower  part  of  the  leg,  or 
the  muscular  branches  of  the  calf,  which  are  affected. 

Considering  the  frequency  with  which  thrombosis 
occurs  in  varicose  veins,  it  is  remarkable  that  it  is 
comparatively  seldom  attended  with  serious  symptoms. 
There  is  usually  but  little  constitutional  disturbance,  and 
the  local  discomfort  is  often  but  slight ;  the  chief  danger 
is  of  displacement  of  the  clot  and  consequent  embolism. 
This  serious  event  is  fortunately  not  of  very  common 
^   Transactions  of  Pathological  Society  of  Lo?idon^  vol.  xxix,,  p.  344. 


34  Phlebitis  and  Thrombosis 

occurrence,  but  it  is  a  danger  which  ought  always  to  be 
borne  in  mind  in  the  treatment  of  such  cases,  particularly 
those  in  which  the  blocked  vein  is  near  a  joint  or  in 
direct  communication  with  the  main  trunk,  as,  for 
instance,  in  the  neighbourhood  of  the  knee  or  of  the 
saphenous  opening. 

Gouty  Phlebitis. — Since  the  publication  in  i865  of  Sir 
James  Paget's  well-known  lecture,  gouty  phlebitis  has 
been  a  well-recognised  disease.  There  can  be  no  doubt 
that  persons  of  gouty  habit  or  ancestry  are  more  than 
commonly  liable  to  phlebitis,  and  that  in  them  the  affec- 
tion has  usually  certain  distinguishing  characters.  To 
quote  Sir  James  Paget's  description  :  '  Gouty  phlebitis  is 
far  more  frequent  in  the  lower  limbs  than  in  any  other 
part ;  but  it  is  not  limited  to  the  limb  that  is,  or  has  been, 
the  seat  of  ordinary  gout.  It  affects  the  superficial  rather 
than  the  deep  veins,  and  often  occurs  in  patches,  affecting, 
for  example,  on  one  day  a  short  piece  of  a  saphenous 
vein,  and  on  the  next  day  another  separate  piece  of  the 
same,  or  a  corresponding  piece  of  the  opposite  vein,  or  of 
a  femoral  vein.  It  shows  herein  an  evident  disposition 
towards  being  metastatic  and  symmetrical — characters 
which,  I  may  remark  by  the  way,  are  strongly  in  favour 
of  the  belief  that  the  essential  and  primary  disease  is  not 
a  coagulation  of  the  blood,  but  an  inflammation  of 
portions  of  the  venous  walls.'^ 

Sometimes  gouty  phlebitis  begins  in  the  deep  veins  of 
the  calf,  of  which  the  first  symptom  may  be  a  sudden  and 
acute  cramp-like  pain,  which  is  soon  followed  by  deeply- 
seated  tenderness  to  pressure.     There  is   a  tendency  to 

^  'Clinical  Lectures  and  Essays,'  p.  293,  1875.  See  also  Sir 
Prescott  Hewett  in  Presidential  Address  to  the  Clinical  Society 
■{Transactions,  vol.  vi.,  p.  xxxvii),  who  relates  cases  of  gouty  phlebitis, 
and  points  out  that  it  often  begins  in  the  back  of  the  leg,  midway 
between  the  heel  and  the  ham. 


Phlebitis  and  Thrombosis  35 

frequent  recurrences  of  the  attacks,  which  are  especially 
apt  to  occur  when  the  patient  is  fatigued  or  below  the 
usual  standard  of  health.  It  is  sometimes  the  only  mani- 
festation of  gouty  inheritance,  but  is  frequently  combined 
with  other  obviously  gouty  symptoms.  It  is  not  usually 
attended  with  much  constitutional  disturbance. 

An  example  of  troublesome  and  frequently  recurring 
phlebitis  occurred  in  a  patient  from  whom  I  had  on  two 
occasions  removed  uric  acid  calculi  by  lithotrity.  He 
lived  most  abstemiously  and  on  a  most  carefully  regulated 
diet,  but  nevertheless  had  frequent  attacks  of  phlebitis, 
alternating  with  eczema,  cystitis,  and  other  symptoms  of 
the  uric  acid  diathesis. 

It  seems  to  me,  however,  that  it  is  the  fashion  at  the 
present  time  to  attribute  many  cases  of  phlebitis,  as  of 
other  diseases,  to  gout  or  the  uric  acid  diathesis,  when 
there  is  no  evidence  whatever  of  either  the  presence  or 
the  inheritance  of  gout. 

Phlebitis  is  sometimes  seen  in  association  with,  or 
during  the  convalescence  from,  acute  rheumatism,  but  I  do 
not  think  that  this  is  sufficiently  common  to  justify  the 
inference  that  there  is  any  special  connection  between  the 
two  diseases. 

Syphilitic  phlebitis  occurs  in  two  forms.  In  one  variety 
the  superficial  venous  trunks  are  attacked,  chiefly  those  of 
the  lower,  but  sometimes  those  of  the  upper,  extremities. 
The  walls  of  the  veins  undergo  inflammatory  thickening, 
and  thrombosis  ensues.  This  is  seen  in  the  early  erup- 
tive period.  Later  in  the  course  of  the  disease  a  nodular 
phlebitis  occurs,  attacking  chiefly  the  subcutaneous  veins 
of  the  lower  limbs,  especially  those  which  are  varicose  or 
sclerosed.  The  condition  is  characterized  by  nodular 
thickenings  of  the  venous  coats,  with  limited  thrombosis. 
It  is  said  to  occur  also  in  the  corpus  cavernosum  and  in 

3—2 


36  Phlebitis  and  Thrombosis 

the  spermatic  cord.  In  neither  form  is  there  usually  any 
considerable  constitutional  disturbance,  but  the  affected 
veins  are  painful  and  tender.  The  disease  yields  to  the 
usual  antisyphilitic  treatment.^ 

Thrombosis  is  frequently  met  with  during  convalescence 
from  enteric  fever,  and  is  not  uncommon  in  other  condi- 
tions of  exhaustion  such  as  result  from  prolonged  or 
serious  illness,  and  in  the  late  stages  of  phthisis.  It 
occurs  occasionally,  but  not  often,  in  the  acute  stage  of 
enteric  fever. 

Professor  A.  E.  Wright  and  Dr.  H.  H.  G.  Knapp^  have 
proved  that  the  coagulability  of  the  blood  is  diminished 
in  the  acute  stage,  but  increased  in  the  convalescent  stage 
of  typhoid  fever  ;  the  coagulation  time  being  four  and 
a  half  minutes  in  the  convalescent  stage,  as  compared  with 
twenty  minutes  during  the  pyrexia.  They  show,  more- 
over, that  the  blood  of  these  convalescents  is  not  only 
much  more  coagulable  than  the  normal,  but  that  it  also 
contains  twice  the  normal  amount  of  lime  salts  ;  whereas, 
if  the  lime  salts  are  brought  within  the  normal  limits,  the 
coagulability  is  reduced  to  even  less  than  that  of  normal 
blood. 

The  authors  suggest  that  the  increased  coagulability  of 
the  blood  of  typhoid  convalescents  is  dependent  upon  an 
excess  of  lime  salts,  and  that  this  excess  is  derived  from 
the  milk  upon  which  typhoid  patients  are  chiefly  fed. 
Cow's  milk,  it  is  noted,  contains  i  part  in  600  of  lime,  as 
compared  with  i  part  in  800  contained  in  lime-water. 

The  remedy  indicated  is   the  administration  of  citric 

^  See  Papers  byJulHen,  Barthelemy,  E.  Hoffmann,  etc.,  in  Transac- 
tions of  the  Fifth  hiternatiojial  Dermatological  Co7tgress,  1904,  vol.  ii., 
part  i.,  pp.  225-265. 

2  '  On  the  Causation  and  Treatment  of  Thrombosis  occurring  in 
Connection  with  Typhoid  Fever,'  Transactions  of  the  Royal  Medical 
and  Chiriirgical  Society^  vol.  Ixxxvi.,  p.  i,  1903. 


Phlebitis  and  Thrombosis  zi 

acid  as  a  decalcifying  agent ;  and  in  seven  patients,  in  all 
of  whom  the  blood  was  found  to  be  abnormally  coagulable, 
it  was  observed  that  the  administration  of  citric  acid 
(36  grains  three  times  a  day)  was  followed  by  a  decalcifi- 
cation of  the  blood  and  a  corresponding  diminution  of  its 
coagulability.  It  is  suggested  that,  with  a  view  to  restrict- 
ing the  intake  of  lime  salts,  the  milk  given  might  be  partially 
decalcified,  and  thus  rendered  more  easily  digestible  and 
less  constipating.  This  can  be  effected  by  adding  to  each 
pint  of  milk  from  20  to  40  grains  of  citrate  of  soda. 

These  valuable  suggestions  appear  to  me  to  be  applicable 
to  many  other  conditions  besides  typhoid  fever. 

Dr.  W.  W.  Keen,  of  Philadelphia,^  in  his  work  on  *  The 
Surgical  Complications  and  Sequels  of  Typhoid  Fever,' 
collected  128  cases  of  venous  thrombosis  following  fever. 
Of  these, '  only  four  involved  the  upper  extremity  alone,  two 
involved  both  the  arm  and  leg,  and  all  the  other  122  cases 
were  limited  to  the  lower  extremities.'  He  observes  that, 
whereas  arterial  thrombosis  occurs  with  almost  equal 
frequency  on  the  two  sides  of  the  body,  two-thirds  of 
the  cases  of  venous  thrombosis  were  on  the  left  side  ; 
and  that  both  forms  of  thrombi,  arterial  and  venous,  'form 
most  frequently  during  or  just  after  the  period  of  greatest 
cardiac  weakness — a  weakness  felt  most  at  such  distant 
points  as  the  legs.'  Of  148  cases,  58  occurred  in  the 
second  and  third  weeks. 

The  influence  of  the  enfeebled  circulation  is  also  shown 
in  the  location  of  the  thrombus.  '  The  coagulation  takes 
place  at  points  mechanically  favourable  to  slowing  of  the 
current — e.g.,  the  bifurcation  of  arteries  and  the  valves  of 
the  veins.^     Dr.  Keen  also  gives  reasons  for  thinking  that 

^  'The  Surgical  Complications  and  Sequels  of  Typhoid  Fever,'  by 
W.  W.  Keen,  M.D.,  LL.D.,  London,  1898,  p.  74. 
2  Op.  cit.,  p.  363. 


38  Phlebitis  and  Thrombosis 

some  at  least  of  the  cases  of  necrosis  of  bone  following 
typhoid  may  be  due  to  thrombosis  of  the  arteries  or  veins.^ 

Dr.  Murchison^  recorded  a  remarkable  case  in  which, 
during  the  course  of  a  severe  attack  of  typhus  fever,  gan- 
grene of  both  legs  occurred  in  consequence  of  thrombosis 
of  the  iliac  and  femoral  arteries,  and  of  the  femoral  and 
popliteal  veins  of  the  left  limb.  The  patient,  a  woman  forty- 
five  years  of  age,  died  on  the  forty-first  day  of  illness.  Dr. 
Murchison  points  out  that,  although  there  was  gangrene  of 
both  legs,  there  was  swelling  only  of  the  left  leg,  in  which 
the  vein,  as  well  as  the  artery,  was  obstructed.  He  also 
remarks  that  in  the  venous  thrombosis  occurring  in  con- 
nection with  fever  it  is  almost  invariably  the  left  lower 
limb  which  is  affected. 

Chlorosis, — This  is  a  disease  in  which  it  is  well  known 
that  there  is  an  especial  liability  to  thrombosis.  This 
depends,  no  doubt,  upon  the  condition  of  the  blood,  in 
which  there  is  a  great  diminution  both  of  the  number  of 
red  corpuscles  and  also  of  their  contained  haemoglobin. 

The  relatively  greater  number  of  white  corpuscles  in 
chlorosis  and  their  slow  movement  along  the  walls  of  the 
bloodvessels  are  conditions  favourable  to  the  occurrence 
of  thrombosis,  as  also  is  the  increase  in  the  number  of 
platelets  which  has  been  observed.  It  would  seem,  also, 
that  the  chemical  composition  of  the  blood  is  altered,  the 
potassium  being  diminished  and  the  sodium  and  chlorine 
increased.^ 

Dr.  Lee  Dickinson^  has  pointed  out  *  that  the  intra- 
vascular coagulation  brought  about  by  the  injection  of 
foreign  substances  (snake  venom  and  nucleo-proteid)  into 

^  O^.  ciL,  p.  III. 

2  Transactions  of  the  Pathological  Society  of  London,  vol.  xvi.,  p.  93. 

3  Biernacki,  Wiener  Medicinische  Wochenschrift,  1893^  pp.  1721 
and  1765. 

'*  Transactions  of  Clinical  Society  of  London,  vol.  xxix.,  p.  63. 


Phlebitis  and  Thrombosis  39 

the  circulation  of  animals,  takes  place  by  preference  in  the 
venous  system,  and  is  greatly  favoured  by  excess  of 
carbonic  acid  in  the  blood.  Chlorotic  blood,  by  reason  of 
its  poverty  in  haemoglobin,  is  certainly  deficient  in  oxygen, 
and  probably  equally  overloaded  with  carbonic  acid. 
The  comparative  infrequency  of  thrombosis  in  the  cerebral 
sinuses,  where  the  mechanical  conditions  seem  so  favour- 
able, is  perhaps  explained  by  the  observation  of  Dr. 
Leonard  Hill  '  that  the  blood  obtained  from  the  torcular 
Herophili  contained  far  less  carbonic  acid  than  that  from 
the  femoral  vein.' 

Dr.  A.  E.  Wright^  has  shown  that  an  increase  of  the 
carbonic  acid  in  the  blood  much  increases  its  coagulability, 
and  he  relates  a  case  of  haemophilia  in  which  haemorrhage 
was  arrested  by  the  inhalation  of  carbonic  acid  gas. 

Chlorotic  thrombosis  is  apt  to  be  extensive  and 
recurrent.  When  its  seat  is  the  cerebral  sinuses,  it  is  a 
condition  of  extreme  gravity ;  when  affecting  the  ex- 
tremities, its  chief  danger  is  pulmonary  embolism. 

1  Proceedings  of  Royal  Society.,  vol.  Iv.,  p.  279  ;  and  '  On  Methods 
of  Increasing  and  Diminishing  the  Coagulability  of  the  Blood,'  Brit. 
Med.  Jou7'n..,  July,  14,  1894,  p.  57. 

2  Professor  W.  H.  Welch,  in  an  admirable  article  in  Allbutt's 
'  System  of  Medicine '  (vol.  vi.,  p.  200),  analyzes  a  collection  of  78 
cases  of  venous  chlorotic  thrombosis,  from  which  he  deduces  some 
instructive  facts.     These  may  be  tabulated  thus  : 

Of  78  cases  of  venous  chlorotic  thrombosis — 

There  was  thrombosis  of  the  cerebral  sinuses  in  32  (39  per 
cent.).  Six  of  these  had  also  thrombosis  of  the  veins  of  the 
lower  extremities  (19  per  cent.)  ;  in  4  the  thrombus  extended 
into  the  internal  jugular  vein. 

In  50  there  was  thrombosis  of  the  veins  of  the  lower  extremities. 
(Bilateral  in  46  per  cent.  ;  unilateral  in  54  per  cent. — 34  left, 
20  right.  64  per  cent,  began  in  left  limb  ;  29  percent,  in  right 
limb  ;  7  per  cent,  in  both  limbs  simultaneously.  25  percent, 
had  pulmonary  embolism — all  but  2  fatal.) 

In  2  there  was  thrombosis  of  the  veins  of  upper  and  lower 
extremities. 

In  I  there  was  thrombosis  of  the  veins  of  upper  extremities  only. 


40  Phlebitis  and  Thrombosis 

Thrombosis  may  occur  in  the  condition  of  debility 
sequential  to  influenza,  as  to  other  febrile  diseases ;  but  it  is 
also  not  uncommon  during  the  acute  stage  of  the  attack, 
when  it  is  possibly  due  to  the  influenzal  bacillus. 

Dr.  T.  J.  Horder^  has  recorded  two  cases  of  influenzal 
endocarditis  in  which  the  Bacillus  influenzce  from  the 
blood  was  cultivated  during  life.  In  both  cases  there  was 
marked  leucocytosis. 

Thrombosis  is  also  sometimes  associated  with  pneumonia. 
It  has  been  observed  that  inflammatory  exudations  that 
are  associated  with  the  presence  of  the  pneumococcus  show 
a  marked  tendency  to  coagulate.^ 

Peripheral  thrombosis  is  a  well-recognised  complication 
of  appendicitis. 

Notes  of  1,000  cases  of  operation  for  appendicitis  at  the 
London  Hospital  were  furnished  by  Mr.  Hugh  Lett  at  the 
discussion  at  the  Royal  Medical  and  Chirurgical  Society 
in  February,  1905.  Among  these  1,000  cases  there  were 
twelve  of  thrombosis  of  the  veins  of  the  lower  extremities, 
and  one  case  of  pulmonary  embolism. 

Of  442  cases  of  operation  for  appendicitis  at  St. 
George's  Hospital,  of  which  notes  were  furnished  by 
Mr.  Laurence  Jones  for  the  same  discussion,  nine  had 
thrombosis  of  the  lower  limbs  and  three  had  pulmonary 
embolism. 

Of    863    cases   reported    by   Dr.    H.    P.    Hawkins,    of 

Professor  Welch  says  :  '  After  making  due  allowance  for  the 
undoubteoly  disproportionate  representation  of  embolism  of  the  large 
pulmonary  arteries  in  published  records,  this  catastrophe  remains 
sufficiently  frequent  to  impart  a  certain  gravity  to  the  prognosis  even 
of  simple  femoral  thrombosis  in  chlorosis.' 

^  Transactions  of  Royal  Medical  and  Chirurgical  Society^  vol.  Ixxxix., 
p.  I. 

'^  Lazarus-Barlow,  '  Manual  of  Pathology,'  second  edition,  1904, 
p.  197. 


Phlebitis  and  Thrombosis 


4^ 


St.  Thomas's  Hospital,  there  were  two  cases  of  throm- 
bosis of  the  veins  of  leg  and  two  cases  of  pulmonary 
embolism. 

Mr.  Aslett  Baldwin  reported  234  cases  from  the 
Middlesex  Hospital,  with  one  case  of  pulmonary  embolism 
and  thrombosis  of  iliac  veins. 

Mr.  Lockwood,  of  St.  Bartholomew's  Hospital,  con- 
tributed 200  cases,  with  two  cases  of  thrombosis  of  mesen- 
teric veins  and  one  case  of  thrombosis  of  the  iliac  vein. 

Mr.  G.  E.  Gask  reported  795  cases  at  St.  Bartholomew's 
Hospital,  with  five  cases  of  venous  thrombosis. 

Of  125  cases  reported  by  Mr.  H.  S.  Clogg  and  Mr. 
H.  A.  T.  Fairbank,  of  Charing  Cross  Hospital,  there 
was  one  case  of  thrombosis,  both  femoral  veins  being 
affected. 

Three  hundred  and  fifteen  cases  were  collected  by  Mr. 
Ralph  Thompson,  of  Guy's  Hospital,  among  which  were  six 
cases  of  femoral  thrombosis  and  one  of  pulmonary 
embolism. 

Mr.  G.  R.  Turner,  of  St.  George's  Hospital,  reported 
140  cases,  with  one  case  of  thrombosis  of  the  femoral  vein 
and  one  case  of  pulmonary  embolism. 


TABLE  I. 

Operations   for  i\ppENDiciTis,  showing  Number  of 
Cases  of  Thrombosis  and  of  Pulmonary  Embolism. 


London  Hospital    ... 

St.  George's  Hospital 

St.  Thomas's  Hospital 

Middlesex  Hospital 

St.  Bartholomew's  Hospital 

Charing  Cross  Hospital    ... 

Guy's  Hospital 


No.  of 

Cases. 

1,000 

442 

863 

234 
795 
125 
315 


Throm- 
bosis. 
12 

9 

2 

I 

5 

I 

4 


Pulmonary 
Embolism. 

I 

3 

2 

I 


3.77^ 


42  Phlebitis  and  Thrombosis 

Thrombosis  is  also  met  with  in  connection  with  opera- 
tions for  gastric  ulcer  and  other  abdominal  diseases.  Of 
fifty  cases  of  operation  at  St.  George's  Hospital  for  per- 
forated gastric  and  duodenal  ulcer  recorded  by  Mr.  T. 
Crisp  English,  there  were  three  cases  of  thrombosis,  all  of 
the  veins  of  the  left  lower  extremity.^ 

Dr.  A.  H.  Corder,  of  Kansas,  has  collected  232  cases 
of  phlebitis  following  abdominal  and  pelvic  operations. 
In  213  cases  the  left  saphenous  or  femoral  vein  was 
affected. 

Dr.  Corder  asserts  that  phlebitis  occurs  in  about  2 
per  cent,  of  all  abdominal  operations,  and  is  especially 
frequent  after  operations  on  patients  anaemic  from 
hsemorrhage,  as,  e.g.,  abdominal  hysterectomies  for  bleed- 
ing fibroids.^ 

There  still  remain  a  certain  number  of  cases  of  throm- 
bosis and  phlebitis  in  which  no  association  with  any 
precedent  disease  or  injury  can  be  traced,  but  which  occur 
in  apparently  healthy  individuals.  This  is  the  class 
usually  spoken  of  as  '  idiopathic'  In  the  light  of  recent 
researches  and  increasing  facilities  for  the  detection  of 
micro-organisms,  it  seems  probable  that  some  of  these  are 
really  of  infective  origin,  although  the  source  of  infection 
has  not  always  been  discovered.  But  there  are  others  in 
which  neither  clinical  nor  pathological  evidence  of  infec- 
tion can  be  obtained,  and  of  which  it  must  be  admitted 
that  the  origin  is  obscure.  Sir  James  Paget  related  two 
such  cases.2  In  both  of  these  the  upper  extremity  was 
affected,  and  the  patients  were  healthy  men. 

In  the  first  case  4  inches  of  the  axillary  vein  could  be 

^  Transactions  of  the  Royal  Medical  and  Chiriirgical  Society., 
vol.  Ixxxvii.,  p.  27. 

'■^  Journal  of  tJie  American  Medical  Associatiojt,  December  9, 
1905,  p.  1792. 

■^  '  Clinical  Lectures  and  Essays,'  p.  305. 


Phlebitis  and  Thrombosis  43 

felt  blocked.  The  arm  was  swollen,  and  there  were 
enlarged  superficial  veins  over  the  upper  part  of  the  chest. 
Sir  James  Paget  says  :  '  No  cause  whatever  could  be 
traced  for  this  condition — no  injury  or  pressure,  no 
known  inheritance  of  disease,  no  disturbance  of  the 
general  health,  past  or  present.'  With  the  help  of  the 
hot  douche,  warmth,  and  friction,  recovery  took  place  in 
the  course  of  a  year. 

In  the  second  case  the  arm  was  in  a  similar  condition, 
and  no  cause  for  it  could  be  discovered.  '  It  was  uncer- 
tain how  long  this  state  of  the  arm  had  existed  ;  it  had 
been  observed  only  a  week ;  its  rate  of  increase  was 
unknown.'  The  patient  remained  in  the  same  condition 
for  a  month,  and  was  then  treated  by  leeching  and 
mercury,  after  a  fortnight  of  which  he  had  an  attack  of 
scarlatina,  and  while  this  was  running  its  course  all  signs 
of  the  affection  of  the  arm  disappeared.-^ 

I  will  add  another  case. 

A  healthy  man,  fifty-four  years  of  age,  living  a  temperate 
and  healthy  but  busy  life,  was  suddenly  seized  with  acute 
cramp-like  pain  in  the  left  calf.  This  was  on  the  evening 
of  a  somewhat  fatiguing  day,  but  no  unusual  exercise  or 
exertion  had  been  undertaken.  The  pain  subsided  after  a 
few  hours'  rest,  but  next  day  recurred,  when  walking  and 
standing  were  somewhat  painful.  A  careful  examination 
revealed  some  deep-seated  tenderness  in  the  calf,  but  no 
swelling.  The  patient  showed  no  sign  of  illness ;  the 
temperature  and  pulse  were  natural,  the  urine  clear  and 
of  normal  acidity.  He  was  not  anaemic ;  he  had  never 
had  any  signs  of  gout,  nor  was  he  of  gouty  ancestry  ;  he 
was  not  aware  of  having  received  any  injury.  Complete 
rest  was  prescribed  ;  the  patient  was  confined  to  bed,  and 
the  limb  covered  with  a  layer  of  wool  and  lightly  bandaged 

^  '  Clinical  Lectures  and  Essays,'  p.  307. 


44  Phlebitis  and  Thrombosis 

to  a  splint.  Nevertheless,  the  phlebitis  spread  upwards  to 
the  femoral  vein,  with  severe  pain  and  moderate  constitu- 
tional disturbance.  Subsequently  the  right  femoral  vein 
was  attacked,  and  in  the  second  week  symptoms  of 
pulmonary  embolism  occurred.  The  patient,  after  a 
tedious  illness,  gradually  recovered. 

1  have  seen  other  analogous  cases,  and  I  must  admit 
that  I  cannot  explain  them. 

A  paper  was  published  in  1905  on  this  class  of  cases  by 
Dr.  John  Bradford  Briggs,  of  Washington.^  He  describes 
a  variety  of  phlebitis  affecting  the  veins  of  the  extremities, 
and  occurring  in  the  absence  of  all  conditions  that  are 
commonly  recognised  as  predisposing  to  inflammation  of 
the  veins.  The  condition  occurs  suddenly  in  persons 
apparently  in  perfectly  good  health,  and,  without  fever  or 
other  disturbance,  leads  to  obliteration  of  the  affected 
vein.  It  is  apt  to  recur,  and  to  spread  from  the  point  at 
which  the  vein  has  previously  become  obstructed. 

Dr.  Briggs  quotes  cases  in  which  the  saphena,  the 
femoral,  and  the  axillary  veins  were  respectively  the  seat 
of  the  disease.  He  admits  that  the  cases  are  *  obscure 
alike  in  their  pathology  and  in  their  remote  and  imme- 
diate etiology,'  but  thinks  that  the  affection  is  due  to 
sclerosis  of  the  veins,  and  is  concerned  with  the  wall 
rather  than  with  the  contents  of  the  vessel. 

Dr.  Briggs  refers  to  a  French  thesis  by  Dr.  Daguillon,^ 
in  which  is  described  what  the  author  calls  a  primitive 
form  of  phlebitis — i.e.,  a  phlebitis  without  any  immediate 
determining  cause.  It  has  a  special  clinical  picture — that 
of  limited,  localized,  superficial  phlebitis,  affecting  the 
lower  limbs,  causing  slight  local  and  no  general  reaction. 

^  '  On  Recurring  Phlebitis  of  Obscure  Origin,'  by  J.  B.  Briggs, 
M.D.,/okns  Hopkins  Hospital  Bulletin,  June,  1905,  p.  228. 

2  Paris,  1894. 


5. — THE    RELATIONS   OF   THE    ILIAC    ARTERIES    AND    VEINS.       THE    LEFT 
COMMON    ILIAC   VEIN    (w)    IS    SEEN    CROSSED    AT   A   RIGHT   ANGLE 
BY    (a)   THE    RIGHT   COMMON    ILIAC    ARTERY    AND    {/>)    THE 
LEFT    INTERNAL    ILIAC   ARTERY. 

[  To  face  p.  45. 


Phlebitis  and  Thrombosis  45 

It  is  of  slow  evolution,  and  shows  a  progressively  ascend- 
ing march  by  successive  attacks  and  relapses.  The 
prognosis  is  serious,  owing  to  the  facility  with  which 
embolism  occurs.  This  differs  somewhat  from  the  cases 
described  by  Dr.  Briggs,  and  Dr.  Daguillon  believes  that 
the  process  is  mainly  one  of  parietal  thrombosis,  and  *  is 
an  indication  of  a  general  diathetic  influence,  shown  in  an 
arthritic  constitution,  with  or  without  actual  gout ' — a 
statement  which  does  not  appear  to  me  to  throw  much 
light  upon  its  causation  or  pathology. 

It  will  be  observed  that  thrombosis  occurring  in  connec- 
tion with  fever,  chlorosis,  phthisis,  and  other  debilitating 
diseases,  after  operations,  and,  indeed,  whatever  its  cause, 
shows  a  curious  preference  for  the  left  lower  limb.  The 
only  reason  for  this  preference  which,  so  far  as  I  know, 
has  been  suggested  is  the  position  of  the  left  common  iliac 
vein,  the  current  in  which  may  possibly  be  somewhat 
obstructed  by  the  pressure  of  the  right  common  iliac 
artery,  under  which  the  vein  passes.  On  looking  carefully 
at  the  anatomy  of  the  vessel,  I  noticed  that  not  only  was 
the  vein  crossed  by  the  right  common  iliac  artery,  but  also 
by  the  left  internal  iliac  artery  as  it  passes  downwards  to 
the  sacro-sciatic  foramen,  both  of  the  arteries  crossing  the 
vein  almost  at  a  right  angle,  and  in  marked  contrast  to  the 
relations  on  the  other  side  (Fig.  5). 

This  may  not  seem  a  very  strong  reason  for  the  great 
predominance  of  thrombosis  in  the  left  vein,  yet  if  the 
blood  is  in  a  condition  in  which  a  slight  retardation  of  the 
current  would  be  sufficient  to  turn  the  balance  towards 
coagulation,  this  anatomical  difference  may  be  enough  to 
determine  the  thrombus  to  the  left  side.  It  is  possible 
also  that  the  pressure  of  a  loaded  rectum  may  to  some 
extent  interfere  with  the  venous  circulation  of  the  left 
side  of  the  pelvis. 


46  Phelbitis  and  Thrombosis 

Thrombosis  may,  however,  occur  in  the  upper  Hmb.  I 
have  alluded  to  two  cases  of  Sir  James  Paget's. 

Sir  Prescott  Hewett^  recorded  a  case  in  which,  after 
small-pox,  both  axillary  veins,  as  well  as  both  external 
ihac  veins,  became  permanently  blocked.  The  patient, 
'  an  officer  in  a  heavy  cavalry  regiment,  was  nevertheless 
able  to  remain  in  the  service  and  efficiently  to  discharge 
his  duties,  for  a  vast  collateral  circulation  had  been 
developed,  and  there  was  a  mass  of  large  tortuous  veins 
spreading  over  the  belly  and  chest.' 

Dr.  Ormerod^  has  published  a  case  in  which  '  there  was 
complete  obstruction  of  both  innominate  veins,  internal 
jugulars,  subclavians,  and  anterior  and  external  jugulars. 
They  were  filled  with  adherent  clot.  The  clot  was  rather 
firmer  on  the  right  side  than  on  the  left.  A  projecting 
end  of  clot  hung  into  the  superior  cava,  but  was  not 
adherent  there.  The  clot  ceased  at  the  opening  of  the 
azygos.  The  azygos,  and  the  superior  intercostal  opening 
into  it,  were  pervious  and  dilated.  There  was  no  clotting 
in  the  cerebral  sinuses.  The  patient  was  under  Dr.  Gee's 
care,  and  was  admitted  for  mitral  stenosis.  There  was 
much  dilatation  of  the  left  auricle  and  right  chambers.  The 
symptoms  of  thrombosis,  which  developed  in  the  hospital, 
pointed  to  its  commencement  in  the  right  subclavian  vein. 
No  local  cause  could  be  found  for  it  post-mortem.' 

I  have  seen  thrombosis  of  the  veins  of  the  upper  arm 
occurring  in,  and  associated  with,  simple  debility. 

Dr.  F.  C.  Turner  ^  has  recorded  a  case  of  thrombosis  of 
the  innominate,  internal  jugular,  and  subclavian  veins, 
occurring  in  an  anaemic  man,  aged  forty-four  years,  who 
had  suffered  from  severe  haemorrhage  from  a  malignant 

1  Trans xctions  of  CI itiical  Society  of  London^  vol.  vi.,  p.  xxxvii. 

2  Transactiotts  of  Pathological  Society  of  Lo?ido7i,  vol.  xL,  p.  75. 
^  Jbid.,  vol.  xliii.,  p.  64. 


Phlebitis  and  Thrombosis  47 

ulcer  of  the  stomach.  There  was  much  swelHng  of  the 
arm,  shoulder,  and  neck,  and  enlargement  of  the  surface 
veins  over  the  chest  and  upper  arm. 

Dr.  Wilberforce  Smith  has  described^  an  instance  of 
thrombus,  organized  and  adherent  in  the  innominate  and 
subclavian  veins,  in  a  case  of  pulmonary  phthisis.  There 
was  a  cavity  in  the  apex  of  the  lung,  over  which  the  pleura 
was  thickened,  and  the  adjacent  part  of  the  subclavian  vein 
was  thickened  and  narrowed.  Four  weeks  before  death 
cedema  and  lividity  of  the  arm  appeared. 

Besides  these  examples  of  thrombosis  occurring  in  con- 
ditions which  are  of  themselves  of  grave  import,  it  is 
easily  provoked  in  persons  who  are  debilitated  by  over- 
fatigue, anxiety,  starvation,  or  other  depressing  influences. 
Herein,  although  the  debility  is  the  predisposing  cause, 
the  immediate  cause  is  most  often  some  severe  muscular 
effort,  and  the  thrombus  starts  in  the  strained  or  over-used 
muscle.  Such  is  the  origin  of  most  of  the  cases  of  non- 
infective  thrombosis  of  the  upper  limbs,  a  condition  not 
very  often  met  with. 

Pulmonary  Embolism. 

Pulmonary  embolism  may  occur  in  any  case  of  phlebitis 
or  thrombosis,  in  the  course  of  slight  as  well  as  severe 
attacks.  The  second  and  third  weeks  are  the  periods 
most  liable  to  this  danger,  which  is  not  often  met  with 
after  the  sixth  week.  Nevertheless,  fatal  embolism  may  be 
produced  by  violence,  such  as  a  blow  or  severe  pressure 
applied  to  a  blocked  vein,  at  much  later  periods. 

Dr.  Play  fair,  in  a  paper  in  the  Transactions  of  the  Patho- 
logical Society,^  collected  twenty-five  cases  of  thrombosis 
and  embolism  of  the  pulmonary  artery  occurring  in  women 

^  Transactions  of  Pathological  Society  of  London^  vol.  xxxii.,  p.  70. 
^  Ibid.,  vol.,   xviii.,   p.  68,  and   the  Lancet,   1867,  vol.   ii.,  pp.  66, 
93,  153- 


4^  Phlebitis  and  Thrombosis 

after  delivery,  and  pointed  out  that  thrombosis  occurs 
before  the  fourteenth  day,  often  on  the  second  or  third 
day  (fifteen  cases)  ;  but  that  embolism  does  not  occur  until 
after  the  nineteenth  day  (seven  cases). 

The  detachment  of  a  large  venous  thrombus,  and  its 
lodgment  in  the  main  trunk  or  in  one  of  the  chief 
divisions  of  the  pulmonary  artery,  may  cause  almost 
immediate  death.  This  detachment  of  clot  usually 
ensues  upon  some  movement  of  the  limb  or  of  the  body, 
some  sudden  change  of  posture,  or  some  pressure  upon  a 
blocked  vein.  Thus,  sitting  up  in  bed,  which  involves 
flexion  at  the  groin,  stooping,  kneeling,  or  the  movements 
concerned  in  leaving  or  returning  to  bed,  have  often  been 
the  immediate  cause  of  this  disaster. 

Sudden  and  intense  dyspnoea  occurs,  with  great  pain  in 
the  chest,  cyanosis,  and  feeble,  irregular  pulse,  followed 
directly,  or  in  a  few  minutes,  by  death. 

When  smaller  branches  of  the  pulmonary  artery  are 
blocked  the  symptoms  are  less  severe,  and  may  either 
gradually  increase  and  lead  to  a  fatal  end,  or  diminish  and 
be  followed  by  recovery.  In  other  cases  a  localized 
pneumonia,  with  hsemorrhagic  expectoration,  may  ensue. 
I  have  known  this  sequence  of  symptoms  to  recur  several 
times,  with  eventual  recovery  ;  but  the  condition  is,  of 
course,  one  of  grave  danger,  demanding  the  most  absolute 
quiet  on  the  part  of  the  patient. 

Pulmonary  Thrombosis. 

Obstruction  of  the  pulmonary  artery  may  also  occur 
from  thrombosis.  It  is  probable  that  in  some  of  the  cases 
recorded  as  instances  of  pulmonary  embolism  the  obstruct- 
ing plug  may  have  been  formed  in  situ,  and  have  been 
really  due  to  thrombosis.  Dr.  Newton  Pitt^  has  collected 
■^  Trajisactions  of  Pathological  Society  of  London,  vol.  xliv.,  p.  48. 


Phlebitis  and  Thrombosis  49 

orty  cases  of  thrombosis  of  the  pulmonary  artery  out  of 
3,218  autopsies  at  Guy's  Hospital,  and  gives  reasons  for 
thinking  that  the  condition  is  of  much  more  frequent 
occurrence  than  is  usually  supposed. 

In  many  cases  the  clot  forms  gradually,  and  is  situated 
in  the  smaller  branches,  so  that  there  are  no  sufficiently 
characteristic  symptoms  to  enable  a  diagnosis  to  be 
made  during  life.^  Sometimes,  however,  a  thrombus  may 
form  in  a  large  branch,  giving  rise  to  symptoms  similar  to 
those  of  embolism — severe  and  distressing  dyspnoea,  faint- 
ness,  cyanosis,  and  great  circulatory  disturbance.  These 
symptoms  may  subside,  and  recur  at  varying  intervals 
with  each  addition  to  the  clot,  until  at  last  the  complete 
occlusion  of  the  vessel  brings  about  a  fatal  result.  More 
rarely,  thrombosis  of  the  main  trunk  or  its  primary  divisions 
is  a  cause  of  sudden  death. 

Pulmonary  thrombosis  occurs  under  similar  conditions 
to  thrombosis  of  other  arteries  and  veins,  especially  in 
feeble  and  cachectic  states  with  lowered  vitality  and  weak 
circulation  ;  and,  although  degeneration  of  the  coats  of  the 
vessel  is  much  less  common  in  the  pulmonary  than  in  the 
other  large  arteries,  yet  such  disease  may  be  the  starting- 
point  of  a  thrombus. 

I  have  collected  from  the  post-mortem  records  of  St. 
George's  Hospital  for  the  last  ten  years,  which  include 
2,903  necropsies,  the  following  cases  of  venous  thrombosis. 
The  list  shows  the  relative  frequency  with  which  the  veins 
were  affected  in  fatal  cases. 

^  Cf.  Paget,  Transactions  of  Royal  Medical  a?id  Chirurgical  Society, 
vol.  xxvii.,  p.  162,  and  vol.  xxviii.,  p.  353,  who  shows  'that  a  large  and 
quickly  increasing  part  of  the  pulmonary  circulation  may  be  arrested 
without  immediate  danger  to  life,  or  any  striking  indication  of 
what  has  happened.' 


50 


Phlebitis  and  Thrombosis 


TABLE  II. 

Fatal  Cases  of  Venous  Thrombosis,  showing 
Veins  affected. 
Iliac  veins 
Inferior  vena  cava 
Lateral  sinus 
Femoral  ... 
Internal  jugular... 
Saphenous 
Hepatic  ... 
Cerebral  cortex  ... 

Portal      

Superior  mesenteric 

Innominate 

Subclavian 

Splenic    ... 

Renal 

Ovarian  ... 

Inferior  mesenteric 

Pelvic 

Uterine    ... 


the 


31 

cases 

15 

)) 

15 

i> 

12 

>> 

7 

5> 

7 

>) 

5 

>> 

4 

M 

3 

J> 

3 

>> 

2 

>J 

2 

)i 

2 

J> 

2 

)> 

2 

>> 

I 

case. 

I 

)> 

I 

)9 

Dr.  Newton  Pitt  gives  the  following  list  of  venous  thromboses 
found  in  3,128  autopsies  during  seven  years  at  Guy's  Hospital  (Trans- 
actions of  Pathological  Society,  vol.  xliv.,  p.  48). 

Iliac  veins 

Femoral  veins 

Prostatic  veins 

Internal  jugular  vein 

Lateral  sinus 

Uterine  veins 

Inferior  vena  cava . . . 

Innominate  veins   ... 

Renal  vein 

Pelvic  veins 

Portal  veins 

Broad  ligament  veins 

Hepatic  veins 

Superior  mesenteric  veins 

Longitudinal  sinus 

Popliteal  vein 

Subclavian  vein 

Cerebral  veins 

Besides  these  there  were  forty  cases  of  thrombosis  of  the  pulmonary 
artery,  and  twenty-six  cases  entered  as  pulmonary  embolism,  of  which 
Dr.  Pitt  thinks  some  were  more  probably  instances  of  thrombosis. 


34 

cases 

33 

27 

17 

15 

12 

12 

9 
8 
8 

7 
6 

4 

4 

4 

3 

3 

3 

Phlebitis  and  Thrombosis 


51 


14 

cases 

12 

6 

>> 

4 

5) 

Table  III.  shows  the  diseases  in  connection  with  which 
the  thrombosis  occurred. 

TABLE  III. 

Fatal  Venous  Thrombosis,  giving  the  Diseases  of 

Origin. 
Middle-ear  disease... 
Cancer  (various  organs)    ... 
Inflamed  varix 
Appendicitis 
Gastric  ulcer 
Ovariotomy... 
Abscess  of  liver 
Peritonitis   ... 
Puerperal  septicaemia 
Inflammation  of  uterus 
Ulceration  of  bowel 
Heart  disease 
Pleurisy 
Cystitis 

Stricture  and  prostatic  abscess^  ... 
Pyosalpinx  ... 
Ansemia 
Phthisis 

Suppurating  ovarian  cyst ... 
Necrosis  of  femur  ... 
Ulceration  of  leg    ... 
Impacted  tooth-plate  in  oesophagus 
Gonorrhoea... 
Lardaceous  disease 
Gall-stones... 
Renal  calculus 
Cirrhosis  of  liver     ... 
Pneumonia  ... 
Pancreatitis... 
Sclerosis  of  spinal  cord 
Suppuration  of  hip-joint  ... 
Fractured  leg 
Actinomycosis 
Uterine  hsemorrhage 
Operation  for  radical  cure  of  hydrocele 
Empyema    ... 

^  This  was  the  only  case  in  which  gangrene  occurred,  and  there 
was  thrombosis  of  the  external  iliac  and  femoral  arteries,  as  well  as  the 
femoral  and  profunda  veins. 

4—2 


I  case. 


52 


Phlebitis  and  Thrombosis 


Thrombosis  of  the  pulmonary  artery  occurred  in 
eight  cases  in  connection  with  the  conditions  shown  in 
Table  IV. 


TABLE  IV. 

Diseases   in   connection  with  which  Thrombosis 
OF  Pulmonary  Artery  occurred. 


Sex. 

Age 

Cirrhosis  of  liver 

Female     . 

•     41 

Radical  cure  of  hydrocele 

Male 

•     47 

Pleurisy 

.     18 

Carcinoma  of  stomach 

.     66 

Gastric  ulcer  ... 

•     49 

Appendicitis    ... 

.     58 

Tropical  abscess  of  liver  (exhaustion) 

•     32 

Disease  of  heart 

•      4 

Phlebitis  and  Thrombosis 


53 


Fatal  pulmonary  embolism  occurred  in  fifteen  cases  in 
connection  with  the  conditions  shown  in  Table  V.,  of 
which  it  will  be  observed  that  eleven  had  reference  to 
abdominal  disease. 


TABLE  V. 

The   Conditions  in  connection  with  which  Fatal 
Pulmonary  Embolism  occurred  in  Fifteen  Cases. 


Thrombosis  of  varicose  saphenous  vein    ... 

>3  J)  ))  JJ  ••• 

Ovariotomy  :  Thrombosis  of  both  internal 
iliac  veins  and  inferior  vena  cava 

Ovariotomy :  Thrombosis  of  saphenous 
vein 

Removal  of  cyst  of  broad  ligament :  Throm- 
bosis of  femoral  and  iliac  veins  ... 

Pyosalpinx :  Thrombosis  of  ovarian  and 
iliac  veins  ... 

Appendicitis:  Operation    ... 

Gastric  ulcer :  Thrombosis  of  internal  iliac 
vein 

Empyema :  Thrombosis  of  internal  iliac 
vein 

Renal  calculus :  Thrombosis  of  femoral 
vein... 

Ulceration  of  rectum,  pelvic  abscess : 
Thrombosis  of  renal  vein 

Abscess  of  liver :  Thrombosis  of  hepatic  veins 

Tubercular  peritonitis  :  Thrombosis  of  iliac 
veins 

Thrombosis  of  uterine  veins 

Fractured  leg  :  Thrombosis  of  veins  of  leg 


Sex. 

Male 

Female 

Age. 

36 

40 

J) 

54 

}  J 

41 

>j 

42 

29 
21 

23 

>} 

27 

Male 

44 

Female 

Male 

43 
34 

3> 

Female 
Male 

51 
53 
31 

54 


Phlebitis  and  Thrombosis 


TABLE  VI. 

The  Veins  in  which  Thrombosis  occurred  in  con- 
nection WITH  Fatal  Pulmonary  Embolism. 


Iliac  veins    ... 

...     6  cases 

Saphenous  veins     ... 

.-.     3      „ 

Femoral  veins 

...       2        „ 

Inferior  vena  cava  ... 

...     I  case 

Renal  vein 

...     I      „ 

Hepatic  vein 

...     I      „ 

Uterine  vein 

...     I      „ 

Ovarian  vein 

...     I      „ 

Veins  of  leg 

...     I      „ 

The  symptoms  of  simple  non-infective  phlebitis  are 
chiefly  those  of  a  localized  thrombosis  ;  the  constitutional 
disturbance  if  the  case  is  uncomplicated  is  not  usually 
severe.  There  may  be  an  initial  rigor,  followed  by  a  rise  of 
temperature  and  pulse,  but  more  often  the  first  noticeable 
symptom  is  pain,  felt  most  commonly  in  the  left  calf. 
This  pain  may  at  first  be  intermittent,  subsiding  for  a 
few  hours  and  then  recurring  with  increased  severity;  if 
the  deep  veins  are  affected,  it  is  of  cramp-like  character. 
These  symptoms  are  coincident  with  the  formation  of  a 
thrombus  and  the  commencement  of  phlebitis.  If  the 
phlebitis  spreads  the  temperature  rises,  perhaps  to  ioi°  or 
102°  F.,  and  there  is  sometimes  sweating  ;  pain  increases, 
especially  if  the  large  veins  are  concerned,  and  there  is 
local  tenderness.  The  amount  of  oedema  is  variable,  for 
the  occurrence  of  oedema  in  cases  of  venous  obstruction 
depends  upon  a  variety  of  conditions,  and  is  by  no  means 
the  simple  matter  which  it  has  been  sometimes  repre- 
sented. It  results  from  *  a  disturbance  of  the  normal 
equilibrium   which    exists    between    blood,   bloodvessels. 


Phlebitis  and  Thrombosis  55 

tissues,  and  lymphatics.'^  Much  will  depend  upon  the 
rapidity,  extent,  and  position  of  the  thrombosis,  the  con- 
dition of  the  venous  coats,  the  possibility  of  collateral 
circulation,  the  force  of  the  blood-stream,  the  precedent 
degree  of  venous  and  arterial  pressure,  and  the  composi- 
tion of  the  blood.  Variations  in  these  factors  account 
for  the  remarkable  differences  observed  as  to  the  occur- 
rence of  oedema  in  venous  obstruction  ;  thrombosis  of  the 
femoral  vein  or  inferior  vena  cava,  for  instance,  may  be 
attended  by  extreme  oedema,  by  very  little,  or  by  none. 

Doubtless  the  production  of  cedema  depends  largely,  as 
Cohnheim  taught,  upon  increased  intravascular  pressure, 
increased  permeability  of  the  vessel  wall,  or  both  of  these 
conditions.  The  obstruction  to  the  return  of  venous 
blood  caused  by  the  thrombus  will  give  rise  to  increased 
intravascular  pressure  behind  the  obstruction,  and  the 
interference  with  the  nutrition  of  the  capillary  endothelium 
will  lead  to  increased  permeability  of  the  capillary  walls, 
and  therefore  to  the  easier  transudation  of  serum.  This 
will  also  be  influenced  by  the  hydrostatic  pressure,  as 
seen  in  the  effect  of  position,  and  the  greater  frequency 
of  oedema  in  connection  with  thrombosis  of  the  lower 
than  of  the  upper  limbs. 

But  this  is  not  sufficient  to  account  for  all  the  phenomena 
of  oedema ;  for  if  the  lymphatics  can  carry  off  the  effused 
fluid  there  will  be  no  oedema.  And  the  facility  of  absorp- 
tion depends  not  only  upon  the  quantity,  but  also  upon 
the  quality  of  the  fluid  to  be  absorbed.  The  larger  the 
amount  of  proteid  contained  in  the  fluid,  the  slower  and 
more  difficult  is  absorption,  and  watery  solutions  of 
crystalloids  are  absorbed  with  a  rapidity  proportionate  to 
their  dilution.  The  presence  or  absence  of  inflammation 
is  therefore  of  importance  in  the  production  of  oedema, 
^  Lazarus- Barlow,  '  Manual  of  Pathology,'  1904.  p.  218. 


5 6  Phlebitis  and  Thrombosis 

for  if  inflammation  is  present  the  fluid  which  escapes  into 
the  tissues  contains  more  proteid  and  is  of  higher  specific 
gravity  than  fthat  which  escapes  as  the  result  of  mere 
venous  congestion. 

The  influence  of  the  nervous  system  must  also  be  taken 
into  account,  for,  as  shown  by  Cornil  and  Ranvier,  if  in 
an  animal  a  vein  is  tied  and  the  vaso-motor  nerves 
divided,  the  arteries  dilate,  more  blood  is  carried  to  the 
part,  and  the  tension  in  the  capillaries  leads  to  exudation 
of  fluid  and  to  oedema.  Ranvier  had  previously  shown 
that  if  |the  inferior  vena  cava  is  ligatured  and  the  sciatic 
nerve  is  divided  in  one  limb,  oedema  only  occurs  in  the 
limb  in  which  section  of  the  nerve  has  been  made. 

Dr.  Lazarus- Barlow,  who  has  done  important  work  in 
this  relation,  has  called  attention  to  the  part  played  by  the 
tissues  in  the  production  of  oedema.  He  says:^  'It  is 
astonishing  how  in  all  discussions  concerning  lymph  and 
oedema  formation  the  tissues  have  been  left  out  of  con- 
sideration, when  we  remember  that  every  condition  which 
affects  the  small  bloodvessels,  and  especially  the  capil- 
laries, must  at  the  same  time  affect  the  tissues  also.  In 
some  cases  even  in  which  oedema  occurs  the  tissues  are 
affected  first  and  to  the  greatest  extent.  It  is  a  fault  in 
the  mechanical  explanation  both  of  lymph  and  of  oedema 
formation  that  it  places  the  tissues  absolutely  at  the  mercy 
of  the  vascular  system.  The  amount  of  lymph  which  the 
tissues  receive,  according  to  that  explanation,  does  not 
depend  upon  the  needs  of  the  tissues,  but  upon  the  con- 
dition of  the  bloodvessels.  And  yet  the  whole  raison  d'etre 
of  the  circulating  system  is  the  existence  of  the  tissues. 
Normal  lymph  formation  and  oedema  formation  must  be 
the  ultimate  result  of  at  least  two  processes,  one  in  which 
the  tissue  cells  are  paramount,  the  other  in  which  the 
bloodvessels  are  paramount.' 

^  '  Manual  of  Pathology,'  p.  202  note. 


Phlebitis  and  Thrombosis  57 

During  hsemostasis  the  tissues  are  affected  in  two  ways  : 
they  are  deprived  of  nutriment,  and  the  waste  products  of 
their  own  metabohsm  are  not  removed.  This  leads  to  an 
active  arterial  congestion  and  an  increased  flow  of  lymph. 
Part  of  this  lymph  is  carried  away  by  the  lymphatics,  but 
if  there  is  more  than  can  be  so  disposed  of  oedema  results. 

It  is  evident  that  in  venous  thrombosis  both  these  con- 
ditions are  present :  there  is  diminished  nutrition  of  the 
tissues  and  accumulation  within  them  of  the  products  of 
their  metabolism.  Upon  this  follows  an  increased  flow 
of  lymph,  and  upon  the  capacity  of  the  lymphatics  to 
carry  this  away  depends  the  occurrence  or  not  of  oedema. 
It  has  already  been  pointed  out  that  the  degree  in  which 
absorption  of  effused  fluid  takes  place  depends  upon  the 
nature  of  the  fluid,  and  this  again  will  depend  upon  the 
composition  of  the  blood,  the  condition  of  the  vessels,  and 
the  presence  or  absence  of  inflammation. 

Enough  has  been  said,  I  think,  to  show  that  the  pro- 
duction of  oedema  in  venous  thrombosis  is  the  result  of  a 
variety  of  complex  conditions.  Moreover,  it  will  depend 
somewhat  on  the  size  and  position  of  the  affected  veins. 

If  a  superficial  vein  is  inflamed,  the  skin  over  it  shows 
a  dull  red  line  wider  than  the  vein,  along  which  is  an  area 
of  tenderness  ;  the  vein  may  be  felt  solid  with  clot ;  there 
is  little  or  no  oedema.  If  the  intramuscular  veins  are 
implicated  there  will  be  more  pain,  and  some  deep  swell- 
ing, the  limb  feeling  tight  and  heavy,  but  showing  little 
superficial  oedema.  If  a  main  trunk  is  obstructed,  as  the 
femoral,  there  will  be  more  general  oedema,  and  the  limb 
may  become  tensely  swollen.  There  may  still  be  but 
little  constitutional  disturbance,  and  the  chief  danger  to 
be  apprehended  is  the  detachment  of  clot.  If  the  patient 
is  kept  at  rest  these  symptoms  may  gradually  subside, 
the  circulation  through  the  veins  involved  may  become 


5  8  Phlebitis  and  Thrombosis 

re-established,  and  the  limb  after  a  time  completely  regain 
its  normal  condition.  But  in  many  cases  some  of  the 
affected  veins  are  permanently  obliterated,  and  when 
large  trunks  are  involved  they  are  often  left  with  the 
walls  thickened  and  lumen  diminished  by  the  adhesion 
and  shrinking  of  organized  clot  (Fig.  4).  I  have  found 
some  of  the  smaller  veins  of  the  calf  blocked  by  firm 
adherent  clot  in  cases  where  the  limb  appeared  to  have 
completely  recovered  from  attacks  of  phlebitis.  The 
veins  of  the  lower  extremity  are  much  more  often  attacked 
than  those  of  the  upper  limb,  and  those  of  the  left  more 
often  than  those  of  the  right  limb.  The  disease  begins 
very  commonly  in  the  deep  veins  of  the  left  calf.  In  this 
class  of  cases  there  is  not  so  great  a  liability  to  recurrence 
as  in  those  of  gouty  origin.  I  have  had  the  opportunity 
of  observing  several  patients  for  varying  periods  up  to  ten 
years,  in  whom  there  has  been  no  recurrence  after  a  severe 
first  attack. 

A  satisfactory  subsidence  and  recovery  is,  however,  not 
always  the  rule.  The  thrombus  may  extend  in  the 
direction  of  the  blood-current,  and  so  to  the  larger  trunks, 
causing  increasing  embarrassment  to  the  circulation. 
Thus  from  the  femoral  vein  coagulation  may  spread 
through  the  iliacs  to  the  inferior  vena  cava,  or  from  the 
veins  of  the  neck  and  upper  extremity  to  the  superior 
cava,  and  thus  to  the  heart.  Professor  Humphry  de- 
scribed such  cases  with  characteristic  accuracy  in  a  thesis 
on  coagulation  of  the  blood  in  the  veins,  published  in 
1859.^  I  have  seen  a  case  in  which  the  thrombus  ex- 
tended as  high  as  the  renal  vein,  and  in  which  recovery 
took  place,  but  with  permanent  obstruction  of  part  of  the 

1  '  On  Coagulation  of  the  Blood  in  the  Venous  System  during 
Life,'  by  George  Murray  Humphry,  M.D.,  F.R.S.  :  Macmillan, 
Cambridge,  1859. 


FIG.    6. — PHOTOGRAPH    SHOWING    THE    DEVELOPMENT   OF   THE   SUPERFICIAL 

VEINS   TWENTY-ONE   YEARS    AFTER   OBLITERATION    OF 

PART   OF   THE    INFERIOR   VENA    CAVA. 

(  To  precede  Fig.  7. 


FIG.    7. — PHOTOGRAPH    SHOWING   THE    DEVELOPMENT    OF   THE   SUPERFICIAL 

VEINS    TWENTY-ONE   YEARS    AFTER    OBLITERATION    OF 

PART   OF   THE    INFERIOR   VENA    CAVA. 

To  face  p.  59. 


Phlebitis  and  Thrombosis  59 

vena  cava.  When  this  occurs  an  enormous  development 
of  the  superficial  veins  of  the  groin  and  abdominal  wall 
usually  takes  place  for  carrying  on  the  collateral  circula- 
tion. A  similar  condition  has  been  observed  in  connection 
with  obstruction  of  the  superior  vena  cava,  though  this 
event  is  rare  except  in  consequence  of  the  pressure  of 
intrathoracic  tumours. 

Figs.  6  and  7  are  from  photographs,  showing  the 
development  of  the  superficial  veins  twenty-one  years 
after  obliteration  of  part  of  the  inferior  vena  cava.  In 
this  patient  it  took  about  ten  years  for  these  veins  to 
reach  a  troublesome  degree  of  enlargement,  and  it  is  only 
lately  that  the  circulation  has  become  completely  com- 
pensated, so  that  now  there  is  no  difference  in  the  size  of 
the  limbs  at  night  and  in  the  morning,  and  the  outline  of 
the  muscles  is  easily  perceptible. 

Sir  Thomas  Watson/  in  his '  Lectures  on  the  Principles 
and  Practice  of  Physic,'  has  described  in  his  inimitable 
manner  two  cases  illustrating  the  effects  of  obliteration  of 
the  venae  cavse,  and  has  given  diagrams  which  show  the 
collateral  circulation. 

One  of  these  was  the  case  of  a  man  who  exhibited  in  a 
remarkable  degree  the  results  of  obliteration  of  the 
superior  vena  cava  by  an  aneurism  of  the  innominate 
artery.  The  whole  surface  of  the  thorax  in  front,  with 
that  of  the  shoulders  and  of  part  of  the  abdomen,  was 
thickly  overspread  with  a  network  of  prominent  veins, 
*  whereby  the  blood  descending  from  the  head  found  its 
way  at  length,  through  many  circuitous  channels,  to  the 
heart.' 

The  second  case  related  by  Sir  Thomas  Watson  was 
that  of    a   woman    in    whom  3    inches    of  the    inferior 

^  '  Lectures  on  the  Principles  and  Practice  of  Physic,'  1857,  vol.  ii., 
P-  350- 


6o  Phlebitis  and  Thrombosis 

vena  cava  was  obliterated  by  the  pressure  of  a  tumour  of 
the  liver,  a  great  development  of  the  superficial  veins  of 
the  thorax  and  abdomen  contributing  to  the  collateral 
circulation.  Sir  Thomas  Watson  draws  attention  to  the 
tortuosity  of  the  veins  in  which  the  direction  of  the  current 
is  retrograde. 

Mr.  C.  Mansell  Moullin^  has  recorded  a  case  of  throm- 
bosis of  the  inferior  vena  cava  following  a  fall  on  the  back 
and  over-extension  of  the  spine.  The  vein  was  obliterated 
from  a  point  immediately  below  the  entrance  of  the  renal 
vein,  and  the  left  common  and  external  iliacs  and  the 
femoral  vein  were  blocked.  The  right  leg  was  scarcely 
oedematous  ;  the  left  was  6  inches  more-in  circumference, 
hard,  brawny,  and  severely  ulcerated.  The  contrast  be- 
tween the  two  limbs  was  striking  and  showed  that  even 
when  the  inferior  cava  has  been  obliterated,  if  the  other 
veins  are  not  interfered  with,  a  collateral  circulation  may 
be  established  quite  sufficient  for  all  ordinary  purposes. 

But  complete  and  permanent  obstruction  of  the  inferior 
vena  cava  may  occur  without  any  marked  development  of 
the  superficial  veins,  as  in  a  case  examined  at  St.  George's 
Hospital,  where  the  collateral  circulation  seemed  to  have 
been  carried  on  almost  entirely  by  the  greatly-enlarged 
azygos  veins.  The  patient,  a  woman  of  fifty  years,  died 
of  pneumonia ;  and  post-mortem  it  was  discovered  that 
the  inferior  vena  cava,  from  just  above  the  entrance  of  the 
right  renal  vein  to  immediately  below  the  entrance  of  the 
hepatic  vein,  had  been  converted  into  an  impervious 
fibrous  cord.  The  azygos  veins  were  greatly  dilated  and 
tortuous,  but  the  veins  of  the  surface  of  the  body  were 
not  dilated  nor  prominent.  ^ 

Dissections  of  similar  conditions  in  cases  of  oblitera- 

^   Transactions  of  Clinical  Society  of  Londoji,  vol.  xvii.,  p.  115. 
2  *  Post-mortem  and  Case  Book,'  1896,  No.  145. 


Phlebitis  and  Thrombosis  6i 

tion  of  the  vena  cava  were  described   many  years   ago 
by  Dr.  Matthew  Baillie^  and  by  Mr.  Wilson.^ 

UncompHcated  peripheral  venous  thrombosis  does  not 
cause  gangrene.  When  this  does  occur  it  is  in  conse- 
quence of  arterial  as  well  as  venous  obstruction,  or  else  of 
the  addition  of  inflammatory  disturbance. 

^  Transactio7is  of  Society  for  the  Irnproveinejit  of  Medical  and 
Chirurgical  Knowledge,  vol.  i.,  p.  127,  plate  v. 

^  Ibid.,  vol.  iii.,  p.  65.  See  also  Dr.  Peacock  in  Transactions  of 
Royal  Medical  and  Chirurgical  Society,  vol.  xxviii.,  p.  r,  'On  Throm- 
bosis of  the  Vena  Cava  Superior  ;'  with  References  to  other  Published 
Cases.' 


LECTURE   III 

Thrombosis  of — (a)  cerebral  sinuses ;  (d)  mesenteric  veins  ;  (c)  gastric 
veins ;  (</)  portal  veins ;  (e)  haemorrhoidal  veins  (ischiorectal 
abscess)  ;  (/)  renal  veins  ;  (g)  splenic  veins  ;  (A)  prostatic  veins ; 
(z)  corpus  cavernosum. 

Treatment  of  thrombosis  and  phlebitis. 

Remote  effects  of  thrombosis  :  their  treatment.  —  Importance  of 
developing  deep  collateral  veins. — Cause  of  enlargement  of  the  limb. 

Effects  of  venous  obstruction  on  the  heart. 

General  management  of  cases  of  blocked  veins. 

Simple  non-infective  thrombosis  of  the  cerebral  sinuses  is 
met  with  chiefly  in  overworked  chlorotic  young  women, 
in  children  who  have  suffered  with  long-continued  diar- 
rhoea, and  in  the  subjects  of  exhaustion  such  as  ensues 
towards  the  end  of  fevers.  It  may  also  be  the  result  of 
injury.^  It  commences  most  often  in  the  longitudinal 
sinus,  and  gives  rise  to  much  cerebral  congestion,  with 
minute  hsemorrhagic  extravasations  into  the  brain  sub- 
stance and  fluid  distension  of  the  ventricles.  There  may 
also  be  optic  neuritis.  The  symptoms  are  severe  head- 
ache, drowsiness,  vomiting,  convulsions,  and  paralysis. 
These  may  subside  and  end  in  complete  recovery,  or  they 
may  go  on  to  coma  and  death. ^ 

1  Mr.  Artbuthnot  Lane  has  recorded  a  case  of  thrombosis  of  the 
longitudinal  sinus  after  fracture  of  the  parietal  bone,  there  being  no 
discoverable  injury  of  the  sinus  {Transactions  of  Clinical  Society^ 
vol.  xxiii.,  p.  219). 

'^  Professor  Humphry,  in  the  thesis  alluded  to,  gives  an  admirable 
description  of  such  a  case,  with  the  post-mortem  examination  {op.  cit. , 

62 


Phlebitis  and  Thrombosis  6^ 

I  have  seen  an  instance  in  a  boy  recovering  from  scarlet 
fever,  in  whom,  besides  convulsions  and  coma,  there  was 
protrusion  of  the  globe  of  the  eye,  chemosis,  and  almost 
complete  interference  with  ocular  movement,  presumably 
due  to  thrombosis  of  the  cavernous  and  petrosal  sinuses. 
In  spite  of  these  serious  symptoms  the  boy  recovered. 

In  infective  cerebral  thrombosis  there  will  be  added  to 
the  symptoms  described  the  rigors,  sweating,  and  ir- 
regular temperature  significant  of  pyaemia. 

Dr.  Newton  Pitt,  in  the  Gulstonian  Lectures  delivered 
before  the  Royal  College  of  Physicians  in  1890,^  gives  a 
most  valuable  analysis  of  forty-four  cases  of  sinus 
thrombosis. 


Primary. 

Secondary. 

Ear 

Other 

Disease. 

Causes. 

Total. 

Longitudinal  sinus 

■••    5 

4 

3 

12 

Lateral  sinus 

•••    5 

22 

9 

36 

Cerebral  veins 

•••    5 

I 

I 

7 

Cavernous  sinus 

I 

3 

4 

Circular  sinus 

...  — 

I 

I 

2 

Inferior  petrosal 

...  — 

I 

I 

2 

Superior  petrosal 

...  — 

2 

— 

2 

Primary  thrombosis  occurs.  Dr.  Pitt  points  out,  in 
cases  *  with  a  feeble  cerebral  circulation,  associated  with 
exhausting  diseases.'  *  In  this  form,  owing  to  the  stagna- 
tion of  the  circulation,  clotting  tends  to  take  place  in  the 
sinuses ;  the  clot  becomes  adherent,  but  seldom  infects  the 
blood  or  gives  rise  to  emboli.' 

p.  32).  Dr.  J.  W.  Ogle  recorded  a  case  of  thrombosis  of  the  cerebral 
veins  and  sinuses  in  a  woman  who  died  exhausted  by  rectal  disease, 
in  whom  the  symptoms  were  only  those  of  exhaustion  until  a  short 
time  before  death,  when  there  was  loss  of  the  power  of  speech,  the 
mind  remaining  unaffected  (  Transactions  of  Pathological  Society  of 
London,  vol.  vi.,  p.  31). 

^  Brit.  Med.  fourn.,  1890,  vol.  i,,  p.  774. 


^4  Phlebitis  and  Thrombosis 

Secondary  thrombosis  occurs  in  connection  with  ad- 
jacent diseases,  chiefly  of  the  ear.  Of  thirty- six  cases, 
twenty-two  were  due  to  ear  disease,  and  in  eleven  of  these 
the  clotting  spread  to  the  jugular  vein.  In  the  majority 
of  the  cases  the  symptoms  were  mainly  those  of  pyaemia, 
three-quarters  of  them  dying  from  pulmonary  infection. 
'  Of  the  remaining  cases,  seven  were  traumatic,  three  had 
spread  from  malignant  pustules  or  carbuncles  on  the  face, 
two  from  an  adjacent  pachymeningitis,  one  from  com- 
pression by  a  growth,  and  only  one  from  a  distant  source 
— namely,  from  pyaemia  set  up  by  a  carbuncle  on  the 
back.' 

Dr.  A.  Brayton  BalP  has  published  an  interesting 
contribution  to  this  subject,  in  which  he  makes  a  similar 
division  of  cases  of  intracranial  venous  thrombosis  into 
two  classes  presenting  marked  differences  in  their  etiology 
and  symptomatology.  He  attributes  secondary  throm- 
bosis either  to  the  propagation  of  a  phlebitis,  or  to  the 
direct  prolongation  of  a  thrombus  having  origin  in  otitis 
media,  in  disease  of  the  cranial  bones,  in  septic  wounds, 
and  in  carbuncular  or  erysipelatous  inflammation  of  the  face 
and  head.  Primary  thrombosis  he  connects  chiefly  with 
debilitating  illness  and  enfeebled  circulation,  and  he 
draws  especial  attention  to  the  cases  occurring  in  anaemic 
and  chlorotic  girls  without  any  preceding  symptoms. 
Dr.  Ball  quotes  a  number  of  illustrative  cases,  which 
exhibit  the  variety  and  mobility  of  the  symptoms  ;  and  he 
points  out  that,  '  apart  from  the  fact  that  these  symptoms 
often  show  a  mobility  that  is  uncommon  in  most  cerebral 
affections,  there  is  nothing  distinctive  in  their  character. 
The  diagnosis  in  this  class  of  cases,  when  possible  at  all, 

^  Transactions  of  the  Association  of  American  Physicians^  vol.  iv., 
p.  52.,  '  Thrombosis  of  Cerebral  Sinuses  and  Veins,'  by  A.  Brayton  Ball, 
M.D.,  with  a  bibliography  of  the  subject. 


Phlebitis  and  Thrombosis  65 

must  be  made  from  the  association  of  anomalous  cerebral 
symptoms  with  the  anaemic  state,  from  evidence  in  ex- 
ternal veins  of  backward  pressure  from  the  intracranial 
venous  circulation,  and  from  the  occurrence  of  thrombosis 
in  other  parts  of  the  body,  particularly  the  internal  jugular 
or  the  veins  of  the  upper  or  lower  limbs.' 

Thrombosis  of  the  mesenteric  veins  is  most  often  associated 
with  intestinal  ulceration.  When  it  occurs  in  connection 
with  peripheral  thrombosis  the  onset  is  usually  sudden  and 
the  symptoms  severe.  Vomiting,  rapid  intestinal  distension, 
griping  pain,  and  intestinal  paralysis,  are  the  chief 
symptoms,  leading  often  to  rapid  death. 

I  have  seen  a  case  in  which,  during  the  course  of  a 
femoral  phlebitis,  there  were  symptoms  indicative  of 
thrombosis  of  a  gastric  vein.  The  patient  was  suddenly 
attacked  with  vomiting,  followed  by  a  great  gastric  and 
intestinal  distension,  dyspnoea,  and  severe  pain  in  the  upper 
part  of  the  abdomen.  The  distension  gradually  dimin- 
ished, but  from  the  moment  of  the  attack  there  was 
complete  anorexia  and  an  absolute  cessation  of  salivary 
secretion.  The  digestive  function  was  for  a  time  in  almost 
complete  abeyance :  only  very  small  quantities  of  pep- 
tonized fluid  food  could  be  taken  ;  and  if  the  fluid  entered 
the  stomach  when  the  patient  was  lying  on  the  left  side, 
acute  pain  was  felt,  which  at  once  subsided  if  the  patient 
was  turned  on  to  the  right  side.  The  suppression  of 
salivary  secretion  and  consequent  dryness  of  the  mouth 
led  to  the  collection  and  decomposition  of  pharyngeal 
mucus,  which,  in  spite  of  the  frequent  use  of  antiseptic 
washes,  caused  great  distress.  After  passing  through  a 
period  of  great  exhaustion  the  patient  ultimately  re- 
covered. 

Dr.  Rolleston  has  recorded  in  the  Transactions  of  the 

5 


66  Phlebitis  and  Thrombosis 

Pathological  Society'^  a  case  in  which  there  was  thrombosis 
of  the  superior  and  inferior  mesenteric  veins,  of  the  left 
internal  and  external  iliac  veins,  and  of  the  splenic  vein, 
of  a  man  who  died  after  profuse  diarrhoea  and  hsemate- 
mesis,  and  in  whom  there  was  ulceration  of  the  vermiform 
appendix. 

Dr.  Hilton  Fagge^  described  a  case  of  acute  thrombosis 
of  the  superior  mesenteric  and  portal  veins,  with  rapidly 
fatal  collapse.  A  woman,  aged  thirty-four,  had  thrombosis 
of  both  femoral  veins  sixteen  days  after  confinement.  On 
the  thirty-sixth  day  she  was  attacked  with  violent  pain  in 
the  abdomen  and  vomiting.  Collapse  rapidly  succeeded  : 
*  the  eyes  were  sunken,  pulse  almost  imperceptible,  pain 
coming  on  in  paroxysms,  but  never  completely  intermitting, 
severe  retching,  and  frequent  vomiting  of  a  rather  viscid 
blood-stained  liquid  in  small  quantity.'  She  was  per- 
fectly conscious  till  death,  eleven  hours  from  the  onset 
of  the  attack. 

Thrombosis  of  the  portal  vein  may  arise  by  extension  from 
a  mesenteric  vein  or  from  gastric  or  intestinal  disease.  It 
may  be  due  to  pressure  by  tumours  or  by  the  interstitial 
growth  of  cirrhosis  or  syphilis ;  and  it  may  depend  upon 
disease,  degeneration  or  injury  of  the  coats  of  the  vein. 
The  symptoms  will  vary  with  the  rate  at  which  the 
thrombus  is  formed.  When  the  thrombosis  is  acute, 
ascites  is  rapidly  developed  (the  fluid  quickly  reaccumulat- 
ing  after  tapping),  and  there  may  be  hsematemesis, 
intestinal  haemorrhage,  and  other  evidences  of  portal 
obstruction.  If  the  patient  survives,  a  notable  development 
and  dilatation  of  the  superficial  veins  of  the  abdominal 
wall  becomes  apparent.  If  the  process  is  gradual  there 
may  be  few  or  no  characteristic  symptoms. 

^   Transactions  of  Pathological  Society,  vol.  xliii.,  p.  49. 
^  Ibid.^  vol.  xxvii.,  p.  124. 


Phlebitis  and  Thrombosis  d^j 

Professor  Osler^  has  described  the  case  of  a  man,  aged 
sixty-two,  who  died  two  days  after  admission  to  hospital, 
suffering  from  ascites  and  hsematemesis.  Post-mortem 
the  Hver  was  found  to  be  in  a  state  of  advanced  cirrhosis, 
and  contained  a  large  infarct.  '  The  portal  vein  presented 
a  soft  brown  thrombus,  occupying  the  upper  part  of  the 
trunk,  but  not  completely  obliterating  it  ;  the  branches 
passing  to  the  right  lobe  had  closely-adhering  light  brown 
thrombi  ;  that  passing  to  the  antero-lateral  region,  where 
the  infarct  was  situated,  was  filled  with  a  firm,  solid, 
partially  laminated  clot,  evidently  forrned  some  time 
before  death.' 

In  this  case  Professor  Osier  points  out  that  the  rare  con- 
dition of  infarction  of  the  liver  probably  depended  upon 
the  cirrhosis  and  the  consequent  obliteration  of  many  of 
the  branches  of  the  hepatic  artery. 

In  contrast  with  this,  Professor  Osier  has  related^  the 
case  of  a  man,  aged  twenty-eight,  in  whom  there  had  been 
for  years  complete  obliteration  of  the  portal  vein.  The 
collateral  circulation  was,  however,  so  fully  compensatory 
that  there  was  no  material  interference  with  the  functions 
of  the  organs.  There  were  extensive  communications 
between  the  gastric  and  oesophageal  veins,  and  through 
the  latter  with  the  azygos  and  lower  intercostal  veins 
and  those  of  the  diaphragm,  all  of  which  were  greatly 
enlarged. 

Professor  Welch  ^  has  recorded  a  case  in  which  there 
seemed  good  reason  to  attribute  the  formation  of  a  portal 
thrombus  to  a  blow  on  the  abdomen.  The  case  is  one  to 
be  borne  in  mind  in  regard  to  abdominal  injuries.  '  A  lad 
who   had   received  a  severe  blow  on  the  abdomen  was 

1   Traiisactions  of  Associatioji  of  Aiiiertcaji  PJiysicians^  1887,  p.  137. 
"^  Journal  of  Afiatoniy  and  Physiology,  London,  1882,  p.  208. 
^  Allbutt's  '  System  of  Medicine,'  vol.  vi.,  p.  220. 

5—2 


68  Phlebitis  and  Thrombosis 

admitted  into  Belle  Vue  Hospital  with  extreme  ascites, 
which  had  come  on  within  two  weeks  after  the  injury. 
He  was  repeatedly  tapped,  the  clear  fluid  reaccumulating 
at  first  with  great  rapidity  after  each  tapping,  afterward 
more  slowly,  until,  in  the  course  of  months,  there  was 
complete  recovery.  In  the  meantime  enlarged  veins 
made  their  appearance  over  the  upper  part  of  the 
abdomen.' 

The  dilated  veins  constituting  venous  hcemorrhoids  are 
very  prone  to  become  thrombosed,  especially  when 
protruded  through  the  sphincter.  The  clot  herein  is 
liable  to  the  invasion  of  micro-organisms,  and  the  extension 
of  this  septic  clot  frequently  leads  to  suppuration,  and 
thus  to  the  formation  of  ischiorectal  abscess.  I  have 
several  times  traced  the  thrombosed  vein  from  an  inflamed 
haemorrhoid  into  the  ischiorectal  cellular  tissue  to  the 
spot  where  suppuration  has  occurred,  and  I  am  sure  that 
this  is  no  uncommon  mode  of  origin  of  ischiorectal 
abcess. 

Thrombosis  of  the  renal  veins  may  be  primary  and 
marantic,  or  may  be  the  consequence  of  extension  from 
the  vena  cava;  it  may  also  depend  upon  disease  of  the 
kidney  and  upon  the  pressure  of  neighbouring  tumours. 
When  of  gradual  occurrence  the  symptoms  may  be 
few  and  indistinguishable,  and  the  collateral  circulation 
may  be  sufficiently  developed  for  complete  recovery. 
When  of  sudden  onset  it  is  manifested  by  the  appearance 
of  blood  or  albumin  in  the  urine,  and  may  be  rapidly 
fatal. 

Dr.  W.  W.  Ord-^  has  recorded  the  case  of  a  boy,  aged 

•one  year,  who  was  recovering  from  scarlet  fever,  and  who 

was  suddenly  seized  with  abdominal  pain  and  vomiting, 

rapidly  succeeded  by  collapse  and  death  in  four  hours. 

^  Transactions  of  Pathological  Society  of  London^  vol.  xlvi.,  p.  39. 


Phlebitis  and  Thrombosis  69 

Post-mortem,  the  left  kidney  was  swollen  and  of  dark 
purple  colour,  and  under  the  microscope  showed  great 
engorgement  of  its  vessels,  with  numerous  small  extravasa- 
tions ;  but  there  were  no  signs  of  interstitial  nephritis. 
There  was  thrombosis  of  the  renal  vein  extending  into,  but 
not  occluding,  the  vena  cava. 

Dr.  Theodore  Fisher  ^  has  published  the  case  of  a  girl, 
aged  thirteen,  who  had  been  the  subject  of  old  hip  disease, 
and  who  was  admitted  into  the  Bristol  Royal  Infirmary  on 
account  of  general  oedema  of  three  weeks'  duration. 
There  was  no  history  of  scarlet  fever.  The  urine  con- 
tained 3  per  cent,  of  albumin,  some  blood,  and  granular 
casts.  The  quantity  of  urine  passed  varied  between  15 
and  46  ounces  in  the  twenty-four  hours  during  the  first 
week.  It  then  diminished  rapidly  to  only  12  ounces  the 
day  before  death,  which  occurred  eleven  days  after  admis- 
sion. Post-mortem,  the  kidneys  were  enlarged  and  the 
cortex  swollen,  pale  yellow,  and  opaque.  There  was 
thrombosis  of  both  renal  veins  and  of  the  vena  cava,  and 
also  of  the  pulmonary  arteries.  The  clot  in  the  renal 
veins  was  becoming  organized,  and  that  in  the  pulmonary 
artery  was  channelled. 

Beckman  ^  states  that  thrombosis  of  the  renal  veins  is 
no  uncommon  occurrence  in  infants  dying  with  profuse 
diarrhoea  and  atrophy.  He  has  examined  ten  cases  care- 
fully. The  left  renal  vein  was  the  one  most  often  affected ; 
in  a  few  cases  the  thrombus  extended  into  and  obstructed 
the  inferior  cava.  The  coagula  were  mostly  dark  red,  and 
loosely  adherent  to  the  walls  of  the  vessels.  No  blood  in 
the  urine,  or  other  symptoms,  seem  to  have  been  observed 
during  life. 

1   Transactions  of  Pathological  Society  of  London^  vol.  xlvii.,  p.  113. 
^  '  Year- Book  of  Medicine  and  Surgery,'  i860,  p.  203  (New  Sydenham 
Society). 


70  Phlebitis  and  Thrombosis 

Thrombosis  of  the  splenic  vein  is  usually  due  to  exten- 
sion from  the  vena  cava.  It  may  be  associated  with 
thrombosis  of  other  abdominal  veins,  as  in  Dr.  Rolleston's 
case  already  alluded  to  ;^  it  may  be  the  consequence  of 
suppuration  or  cancerous  disease  of  the  pancreas ;  and  it 
may  be  caused  by  degeneration  of  the  walls  of  the  splenic 
vein.  As  the  process  is  seldom  confined  to  the  splenic 
vein,  there  are  no  characteristic  symptoms,  excepting 
perhaps,  a  rapid  swelling  of  the  spleen. 

Thrombosis  of  the  prostatic  veins  would  seem,  from 
post-mortem  evidence,  to  be  not  very  rare,  and  may 
perhaps  be  the  result  in  some  cases  of  a  past  prostatitis. 
It  is  probably  also  in  some  cases  the  first  step  in  the 
causation  of  prostatic  abscess. 

Thrombosis  in  the  corpus  cavern osttm  of  the  penis  is 
occasionally  met  with,  but  is  not  very  common.  It  is 
usually  associated  with  the  gouty  constitution  or  with 
syphilis,  but  I  have  seen  a  case  in  which  no  such  connec- 
tion could  be  traced. 

Sir  Prescott  Hewett  ^  recorded  two  cases  of  thrombosis 
of  the  corpus  cavernosum  in  men  of  sixty-five  and  fifty-eight 
years,  both  gouty.  In  one  case  there  was  a  single,  hard, 
painless  nodule ;  in  the  second  case  there  were  four 
nodules,  three  on  the  left  and  one  on  the  right  side, 
'  varying  in  size  from  a  pea  to  that  of  a  French  bean. 
They  were  perfectly  circumscribed,  hard  to  the  touch, 
knot-like,  and  painless  when  handled.'  The  nodules  all 
gradually  diminished,  and  in  two  years  two  of  them  had 
disappeared,  no  treatment  having  been  adopted. 

Sir  Dyce  Duckworth  ^  has  recorded  a  case  of  painful 
priapism,  due  to  thrombosis  of  the  corpus  cavernosum, 

1  Transactions  of  Pathological  Society  of  London,  vol.  xliii.,  p.  49. 

2  Transactions  of  Clinical  Society  of  London,  vol.  vi.,  p.  xl. 
^  Ibid.,  vol.  XXV.,  p.  97. 


Phlebitis  and  Thrombosis  71 

which  occurred  in  a  man  of  forty-two  years,  during  a 
distinct  attack  of  acute  gout.  The  condition  persisted 
for  three  weeks,  and  gradually  disappeared. 

Sir  Dyce  Duckworth^  also  quotes  two  similar  cases — one 
in  a  very  gouty  man  of  forty-five  years,  in  whom  the  con- 
dition lasted  three  weeks ;  and  a  second  in  a  man  of  sixty 
years,  also  gouty,  in  whom  a  second  attack  occurred 
after  a  year's  interval. 

The  treatment  of  a  case  of  simple,  non-infective 
phlebitis  or  thrombosis  consists  chiefly  in  the  enforce- 
ment of  complete  rest.  The  point  to  be  kept  in  mind 
is  the  importance  of  taking  every  possible  precaution 
against  the  detachment  of  clot.  This  is  the  chief  danger, 
especially  when  the  larger  venous  trunks  are  involved,  and 
it  belongs  to  the  slight  as  well  as  to  the  severe  cases. 
The  patient  must  be  at  once  and  rigidly  confined  to  bed, 
and  must  avoid  all  exertion  ;  especially  must  he  be  warned 
against  any  straining  effort,  as,  for  instance,  in  defseca- 
tion.  The  bowels,  therefore,  must  be  kept  acting  easily 
by  gentle  laxatives,  and,  of  course,  the  bed-pan  must  be 
used.  The  neglect  of  this  precaution  has  led  to  many 
disastrous  results.  If  there  be  troublesome  cough,  laryn- 
geal sedatives  must  be  used  and  easy  expectoration  pro- 
moted, so  as  to  avoid  the  disturbance  and  effort  which 
cough  involves. 

In  gouty  phlebitis  the  amount  of  solid  food  should  be 
diminished,  but  distilled  water  should  be  taken  freely 
(2  or  3  pints  in  the  twenty-four  hours).  This  should  be 
mixed  with  a  carminative  (as  ginger),  as  care  should  be 
taken  to  avoid  flatulence,  for  any  distension  of  the 
abdominal  viscera  is  a  serious  embarrassment  to  the 
circulation.  An  occasional  dose  of  calomel  is  usually 
beneficial. 

^  Transactions  of  Clinical  Society  of  London^  vol.  xxv.,  p.  loo. 


12  Phlebitis  and  Thrombosis 

I  have  already  alluded  to  Professor  Wright's  ^  observa- 
tions, showing  that  the  administration  of  citric  acid  is 
followed  by  a  decalcification  of  the  blood  and  a  corre- 
sponding diminution  of  its  coagulability. 

Mr.  C.  Nepean  Longridge  has  kindly  furnished  me  with 
some  observations  upon  lying-in  women  to  the  same  effect. 
He  also  found  that  by  taking  citric  acid  the  coagulation 
time  of  his  own  blood  was  increased  from  two  minutes 
fort)'-five  seconds  to  three  minutes  thirty-five  seconds, 
without  any  change  of  diet.  I  think,  therefore,  that  citric 
acid  should  certainly  be  given  for  the  treatment  of  throm- 
bosis, as  well  as  for  its  prevention  in  conditions  in  which 
that  danger  is  likely  to  occur.  Having  in  mind  also  the 
difficulty  of  certainly  excluding  the  possibility  of  an  infec- 
tive origin,  and  of  separating  clinically  the  infective  and 
non-infective  cases,  I  hold  it  wise  to  give  quinine  in 
moderate  doses.  It  also  seems  to  me  that  Professor 
Wright's  ^  suggestion,  as  to  decalcifying  the  milk  by  the 
addition  of  citrate  of  soda,  should  be  adopted  wherever 
large  quantities  of  milk  are  given  to  patients  prone  to 
thrombosis.  The  same  author  has  also  proved  experi- 
mentally ^  that  the  coagulability  of  the  blood  is  diminished 
by  ingestion  of  alcohol,  by  drinking  large  quantities  of 
fluid,  and  by  reducing  the  supply  of  food.  Water,  there- 
fore, should  be  freely  taken,  and  freshly-made  lemonade  is 
a  useful  beverage.  The  diet  should  be  light  and  easily 
digestible,  and  may  perhaps  with  advantage  include  some 

1  Brit.  Med.  fotirn.,  July  14,  1894,  p.  57,  and  the  Laticet,  October  14, 
1905,  p.  1096. 

^  Transactions  of  the  Royal  Medical  and  Chirurgical  Society., 
vol.  Ixxxvi.,  p,  I.  See  also  the  Lancet,  July  22,  1893,  p.  194,  Dr. 
A.  E.  Wright  on  '  The  Advantages  of  Decalcified  Milk  in  the  Feed- 
ing of  Infants  and  Invalids';  and  Dr.  F,  J.  Poynton  on  the  same 
in  the  Lancet,  1904,  vol.  ii.,  p.  433. 

•^  Transactions  of  Pathological  Society  of  London,  \o\.  li.,  1900,  p.  298. 


Phlebitis  and  Thrombosis  TZ 

alcohol.  Tobacco-smoking  would  seem  to  be  harmless,  or 
perhaps  even  beneficial. 

Dr.  B.  W.  Richardson  ^  made  a  great  number  of  experi- 
ments on  the  blood  of  a  gentleman  who  was  addicted  to 
constant  smoking.  He  observed  that  in  the  morning 
after  rising,  and  before  smoking,  the  blood  coagulated  in 
two  minutes  with  moderate  firmness,  and  the  corpuscles 
were  generally  natural  in  shape.  '  When  two  or  three 
pipes  had  been  smoked,  a  distinct  change  occurred  in  the 
blood :  it  retained  its  brightness,  but  flowed  freely  and 
coagulated  slowly  and  feebly.  After  a  long  day  of 
smoking — from  fifteen  to  twenty-five  pipes  having  been 
taken — the  blood,  though  still  retaining  its  bright  colour, 
flowed  much  more  readily,  and  would  sometimes  refuse  to 
coagulate  altogether.  Left  for  a  time  in  the  cup  of  a 
microscope-glass,  it  would  thicken  from  a  sort  of  drying 
process,  but  would  not  healthily  coagulate.'  Under  the 
microscope  the  red  corpuscles  showed  some  irregularity 
of  shape  and  did  not  form  rouleaux.  After  a  night's  rest 
the  blood  resumed  its  normal  condition. 

Dr.  Richardson  also  observed  that  the  blood  of  jaundiced 
persons  coagulated  slowly  and  feebly.  He  also  found  that 
the  administration  of  ammonia  caused  similar  changes  in 
the  corpuscles,  and  a  decrease  in  the  coagulability  of  the 
blood. 

It  has  been  observed  that 

The  Coagulahiliiy  of  the  Blood  is  increased  by — 

Carbonic  acid. 

Lime  salts  (calcium  chloride,  calcium  lactate). 

Milk. 

Magnesium  carbonate. 

Restriction  of  fluid. 

^  '  The  Cause  of  the  Coagulation  of  the  Blood,'  by  B.  W.  Richard- 
son, M.D.,  1858,  p.  loi. 


74  Phlebitis  and  Thrombosis 

The  Coagulability  of  the  Blood  is  diminished  by — 

Oxygen. 

Alcohol. 

Ammonia. 

Restriction  of  food. 

Diminution  of  lime  salts. 

Large  quantities  of  fluid. 

Citric  acid. 

Rhubarb. 

Acid  fruit-juices. 

Acid  wines. 

Tobacco-smoking. 

The  treatment  must,  however,  be  modified  to  meet  the 
special  conditions  of  those  in  whom  the  phlebitis  is  a 
complication  of  other  serious  diseases,  as,  for  instance, 
in  chlorosis,  influenza,  and  enteric  fever.  I  do  not  think 
that  in  any  case  depletion  is  desirable.  The  local 
measures  should  be  directed  to  relieving  pain  and  in- 
suring rest  to  the  affected  limb.  For  the  relief  of  pain 
nothing  is  so  effectual  as  the  application  of  heat ;  and,  as 
it  is  most  important  to  disturb  the  limb  as  little  as  possible, 
it  is  best  to  use  dry  heat.  Thin  flannel  bags,  filled  with 
bran  and  heated  in  an  oven,  are  convenient  for  this 
purpose  ;  they  are  light  and  retain  heat  for  a  considerable 
time.  When  only  a  small  portion  of  vein  is  involved,  a 
hot  lead  and  opium  lotion,  or  a  fomentation  of  boracic 
lint  covered  by  jaconet,  is  comfortable  ;  but  the  extensive 
use  of  wet  applications  is  inconvenient  and  involves 
frequent  disturbance.  When  pain  is  not  severe,  the  most 
comfortable  dressing  is  a  layer  of  Gamgee  tissue  secured 
round  the  limb  by  a  many-tailed  bandage,  the  skin  having 
been  first  dusted  over  with  powdered  boracic  acid.  If  the 
inflamed  vein  is  superficial  and  tender,  it  is  well  to  paint 
along  the  line  of  redness  a  thick  lotion  of  oxide  of  zinc, 
glycerine,  and  carbolic  acid  in  water.  I  have  never  seen 
the  least  advantage  from  the  application  of  belladonna 


"^%^^si^^'^ 


FIG.    8. — THROMBOSIS    OF    FEMORAL    VEIN,    BUT    NO   THICKENING    OF 

VENOUS    COATS. 

i'l'oface p.  75. 


Phlebitis  and  Thrombosis  75 

which,  though  often  recommended,  seems  to  me  to  be 
disagreeable  and  useless.  When  the  veins  of  the  upper 
limb  are  affected,  the  arm  should  be  extended  upon  a 
pillow  raised  slightly  above  the  level  of  the  body  and  away 
from  the  side.  It  is  best  secured  by  wrapping  a  second 
pillow  partially  round  the  limb  and  fixing  it  by  two  or 
three  separate  strips  of  wide  bandage.  In  this  way  sudden 
movements  in  sleep  or  otherwise  are  prevented.  A  similar 
arrangement  can  be  adapted  to  the  leg,  or  a  well-padded 
splint  may  be  applied  and  the  limb  slung  from  a  cradle. 

I  wish  now  to  consider  some  of  the  more  remote  effects 
of  phlebitis,  for  it  seems  to  me  that  too  little  attention  has 
been  paid  to  conditions  upon  the  management  of  which 
will  often  depend  much  of  the  future  comfort  and  activity 
of  the  patient. 

After  a  severe  attack  of  phlebitis,  especially  if  the  large 
venous  trunks  have  been  involved,  some  of  the  affected 
veins  will  probably  be  left  more  or  less  obstructed.  The 
lumen  of  the  vein  may  be  completely  filled  by  blood-clot, 
which,  becoming  gradually  organized,  obliterates  the 
canal,  and  converts  the  vein  into  a  solid  cord ;  or  the  clot 
may  be  tunnelled  and  a  channel  for  the  blood  remain, 
either  through  the  thrombus  or  between  it  and  the  wall 
of  the  vein.  In  non-infective  phlebitis  or  thrombosis 
the  outer  coat  of  the  vein  is  not  materially  thickened,  and 
the  diminished  lumen  of  the  vessel  depends  upon  the 
organization  and  contraction  of  the  adherent  clot  (Fig.  8). 
But  in  phlebitis  originating  in  an  infecting  focus  or  wound 
the  outer  coat  is  always  much  infiltrated,  and  may  be  left 
permanently  thickened  and  indurated  (Fig.  4).  In  this 
way,  and  by  subsequent  contraction,  the  lumen  of  the 
vessel  is  encroached  upon  and  much  diminished,  and  this 
may  be  still  further  narrowed  by  the  addition  of  organized 
clot  from  within. 


76  Phlebitis  and  Thrombosis 

When  a  main  venous  trunk,  such  as  the  femoral  or  ihac, 
is  permanently  blocked,  certain  changes  result  in  the  limb 
concerned.  I  will  take  as  an  example  a  case  in  which 
the  femoral  and  external  iliac  veins  are  obliterated.  At 
first,  whenever  the  limb  is  dependent  or  the  upright 
posture  is  assumed,  the  veins,  both  superficial  and  deep, 
become  full,  the  limb  becomes  painful,  tense,  and  some- 
what swollen,  and  a  sense  of  constriction  is  felt  at  the 
groin  and  in  the  popliteal  space.  The  skin  presents  a 
dusky,  congested  appearance ;  the  muscular  power  is 
diminished ;  and,  after  walking  a  short  distance,  severe 
aching  pain  occurs,  which  makes  a  rest  imperative.  If 
the  patient  is  now  placed  recumbent  and  the  limb 
elevated,  the  veins  gradually  become  less  full,  the  skin 
recovers  its  normal  colour,  and  the  pain  subsides ;  but 
the  limb  remains  somewhat  larger  and  firmer  than  its 
healthy  fellow,  and  the  contraction  of  the  superficial 
muscles  is  less  easily  seen.  The  collateral  venous  circula- 
tion begins  to  develop  almost  immediately  upon  the  block- 
ing of  the  main  trunk,  and  in  the  course  of  a  month  or  six 
weeks  some  enlargement  of  the  superficial  veins  at  the 
groin  and  lower  part  of  the  abdominal  wall  becomes 
manifest  (superficial  epigastric,  superficial  circumflex  iliac, 
external  pudic,  etc.)-  This  goes  on  gradually  increasing 
until  the  veins  attain  an  enormous  size,  and  a  number  of 
tortuous  veins  I  inch  or  more  in  diameter  extend  over  the 
groin  and  abdominal  surface  (Figs.  6  and  7,  p.  59). 

At  the  same  time  the  deep  communicating  veins  are 
enlarging,  and  as  the  collateral  circulation  becomes 
developed,  the  upright  posture  causes  less  congestion 
and  swelling,  walking  is  less  painful,  and  the  limb  recovers 
more  quickly  when  rested.  But  the  enlarged  superficial 
veins,  although  assisting  the  return  of  the  venous  blood, 
are  themselves  the  cause  of  much  local  discomfort ;  their 


Phlebitis  and  Thrombosis  "J^ 

distension  gives  rise  to  painful  aching,  and  their  prominence 
and  lack  of  support  render  them  liable  to  injury.  It  is, 
therefore,  desirable  in  all  cases  in  which  a  main  venous 
trunk  is  blocked,  to  favour  as  far  as  possible  the  develop- 
ment of  the  deep  collateral  vessels,  and  to  prevent  the 
excessive  enlargement  of  the  superficial  veins.  It  will  be 
remembered  that  the  return  of  the  blood  through  the  deep 
veins  is  assisted  by  muscular  contraction,  which  has  but 
little  effect  upon  the  veins  of  the  surface ;  and  that  the 
deep  veins,  having  the  support  and  protection  of  the  tissues 
among  which  they  are  placed,  do  not  become  easily 
over-distended  or  varicose  and  are  not  liable  to  injury. 
Evidently,  therefore,  it  is  to  be  desired  that  the  collateral 
circulation  should  depend  as  much  as  possible  upon  the 
deep  veins,  and  as  little  as  possible  upon  those  of  the 
surface.  This  is,  I  think,  a  matter  of  considerable  im- 
portance in  the  management  of  such  cases,  and  a  good 
deal  can  be  done  in  the  direction  indicated.  In  the  first 
place,  it  is  necessary  to  decide  at  what  period  the  use  of  the 
limb  may  safely  be  attempted.  This  requires  careful  con- 
sideration, for  while,  on  the  one  hand,  there  is  the  danger 
of  displacement  of  clot  if  the  limb  is  used  too  soon  ;  on  the 
other  hand,  the  functional  activity  of  the  muscles  is  the 
best  aid  towards  the  development  of  the  deep  collateral 
veins. 

Pulmonary  embolism  is  not  common  after  the  sixth  week 
from  the  formation  of  a  thrombus,  although  instances 
have  been  recorded  of  the  detachment  of  a  clot  by  a  blow 
or  pressure  at  later  periods.  There  are  great  variations  in 
the  time  required  for  the  organization  of  thrombi.  It  must 
be  borne  in  mind  that  this  process  is  really  the  invasion  of 
the  thrombus  by  active  cells  and  new  vessels,  and  the 
gradual  replacement  of  the  blood-clot  by  connective  tissue. 
This  change  needs  for  its  favourable  progress  the  functional 


78  Phlebitis  and  Thrombosis 

activity  of  the  venous  wall,  and  is  inevitably  delayed  by 
the  presence  of  septic  organisms.  In  simple  non-infective 
cases  evidence  of  commencing  organization  may  be  found 
in  a  thrombus  at  the  end  of  a  week,  whereas  in  veins 
the  walls  of  which  have  undergone  degeneration  very 
little  change  may  have  occurred  at  the  end  of  a 
month. 

In  an  uncomplicated  case  of  phlebitis  it  will  probably 
be  safe  at  the  end  of  six  weeks  from  the  last  extension  of 
the  thrombus  to  commence  some  movement  of  the  limb, 
but  this  should  not  be  permitted  as  long  as  there  is  any 
tenderness  over  the  vein,  for  tenderness  implies  the  possi- 
bility of  further  extension  of  thrombus  ;  moreover,  the 
first  movements  should,  of  course,  be  made  with  great 
gentleness  and  caution.  In  cases  of  septic  origin,  and 
also  in  cases  in  which  there  is  disease  or  degeneration  of 
the  veins,  a  longer  time  should  be  allowed  before  move- 
ment. 

The  organization  of  thrombus  in  varicose  veins  is  usually 
very  slow,  and  when  thrombosis  occurs  in  cysts  and  tortuous 
dilatations,  especially  in  veins  near  the  knee  or  in  the  long 
saphenous  in  the  thigh,  the  safest  course  is  to  ligature  the 
vein  and  excise  the  thrombosed  portion. 

When  in  an  uncomplicated  case  of  phlebitis  the  clot  has 
undergone  early  and  rapid  disintegration,  and  the  blood- 
current  through  the  vein  can  be  felt  to  be  re-established, 
movement  may  be  allowed  at  an  earlier  period,  and  may 
be  cautiously  commenced  when  the  vein  is  entirely  free 
from  pain  and  tenderness. 

When  a  large  trunk,  such  as  the  femoral  or  iliac  vein, 
becomes  permanently  blocked,  many  small  superficial 
veins  become  developed,  which  not  infrequently  become 
inflamed  in  consequence  of  some  local  irritation.  A  little 
tenderness  is  felt  on  some  part  of  the  skin,  and  on  careful 


Phlebitis  and  Thrombosis  79 

inspection  a  narrow  branching  line  of  slight  redness  is 
seen,  under  which  is  felt  the  soft  cord  of  a  minute  blocked 
vein.  If  the  limb  is  kept  quiet  for  a  few  days,  and  the 
tender  vein  covered  with  a  warm  lotion  of  boric  acid  or 
lead,  or  painted  over  with  oxide  of  zinc  lotion,  the  little 
vein  usually  soon  becomes  again  pervious,  the  tenderness 
and  redness  subside,  and  the  trouble  is  at  an  end ;  but  if 
the  condition  is  neglected,  the  phlebitis  may  spread  to 
larger  veins,  or  other  small  branches  may  become  in- 
volved, and  a  troublesome  area  of  inflamed  skin  is  left, 
causing  much  irritation  and  annoyance.  When  the 
patient  first  begins  to  walk,  a  soft  elastic  bandage  should 
be  gently  applied  from  the  foot  to  the  groin,  and  carried 
in  a  figure-of-eight  round  the  iliac  region  of  the  abdomen, 
the  skin  having  been  first  dusted  with  powdered  boracic 
acid.  The  upright  posture  should  be  maintained  only  for 
a  very  short  time-at  first ;  a  walk  of  about  ten  minutes  will 
cause  the  limb  to  become  painfully  congested  and  neces- 
sitate a  rest  in  the  recumbent  posture,  with  the  limb  well 
raised.  Standing  should  be  avoided  as  much  as  possible, 
but  the  exercise  of  the  muscles  should  be  gradually  in- 
creased. If  all  goes  well,  and  if  the  blocked  vein  is  quite 
free  from  tenderness,  massage  may  be  commenced  after 
about  three  months.  This  should  consist  of  gentle  rub- 
bing in  an  upward  direction,  the  actual  course  of  the 
blocked  vein  being  avoided,  and  the  limb  dusted  freely 
with  boracic  acid.  It  should  be  done  in  the  evening,  and 
no  exercise  should  be  taken  afterwards.  The  foot  of  the 
bed  should  be  raised  on  blocks  6  or  8  inches  in  height. 
As  more  use  of  the  limb  becomes  possible,  it  will  be  best 
to  substitute  for  the  bandage  a  well-fitting  elastic  stocking. 
If  the  femoral  vein  is  blocked  the  stocking  should  be  in  two 
pieces,  the  lower  reaching  from  the  foot  to  just  below  the 
knee,  the  thigh-piece  from  below  the  knee  to  the  fold  of  the 


So  Phlebitis  and  Thrombosis 

groin,  with  a  peak  ending  in  a  strap  for  attachment  to 
braces. 

If  the  obstruction  extends  above  Poupart's  ligament  to 
the  iliac  veins  or  the  vena  cava,  a  combined  thigh-piece 
and  abdominal  belt  should  be  worn ;  and  this  should  be 
adopted  from  the  beginning,  so  as  to  prevent  as  far  as 
possible  the  enormous  dilatation  of  the  superficial  col- 
lateral veins  at  the  groin  and  iliac  region  which  will 
otherwise  take  place  (Figs.  6  and  7).  Probably  no  care 
will  prevent  considerable  enlargement  of  these  veins,  and 
a  graduated  pad  should  be  introduced  into  the  belt  when 
the  enlargement  becomes  apparent.  But  whichever  part 
of  the  venous  trunk  is  obstructed,  it  is  a  mistake  to  delay 
the  application  of  the  elastic  support  until  the  superficial 
veins  begin  to  dilate  ;  every  effort  should  be  made  from 
the  first  to  encourage  the  return  of  the  blood  by  the  deeper 
branches. 

In  most  cases  the  thigh-piece  can  be  discarded  after 
four  or  five  years,  but  in  some  instances  the  great  develop- 
ment of  the  collateral  veins  of  the  iliac  region  necessitates 
continued  support  and  protection.  Great  care  should  be 
taken  to  avoid  all  constriction  of  the  limb.  Elastic 
stockings  are  often  made  with  a  tight  band  at  the  upper 
limit,  which  acts  like  a  garter.  This  is  harmful  and  un- 
necessary, for  if  the  stocking  is  made  to  measure  and  fits 
well,  it  will  keep  in  place  without  any  such  addition.  The 
patient  should  be  instructed  to  take  every  opportunity  of 
keeping  the  limb  raised,  especially  towards  the  end  of  the 
day.  Exercise  should  be  taken  in  the  early  part  of  the 
day.  Hard  seats,  especially  chairs  with  a  hard  rim  at  the 
front  of  the  seat,  should  be  avoided,  and  a  footstool  used, 
so  as  slightly  to  raise  the  front  of  the  thigh  from  the  chair. 
It  is  astonishing  how  small  an  amount  of  pressure  will 
obstruct  the  venous  circulation,  especially  where  it   de- 


Phlebitis  and  Thrombosis  8i 

pends  largely  upon  the  superficial  veins  :  the  weight  of  the 
arm  resting  upon  the  thigh,  the  weight  of  the  leg  if 
crossed  over  the  opposite  limb,  is  sufficient  seriously  to 
impede  the  venous  return. 

Towards  the  end  of  the  day,  especially  if  there  has  been 
much  standing,  the  limb  will  become  somewhat  swollen, 
heavy  and  congested,  and  this  is  often  accompanied  by  a 
good  deal  of  aching,  itching,  and  discomfort.  The  best 
remedy  for  this  is  a  thoroughly  hot  bath,  followed  by  gentle 
massage  with  the  limb  raised. 

Among  the  remoter  troubles  resulting  from  blocked 
crural  veins  is  the  development  of  a  plexus  of  small 
tortuous  veins  between  the  inner  ankle  and  the  heel,  which 
leads  to  a  condition  of  irritation  and  malnutrition  of  the 
skin  in  that  situation,  which  may  even  go  on  to  ulceration. 
When  these  veins  begin  to  appear,  a  thin  pad  of  lint  or 
felt  may  with  advantage  be  introduced  under  the  stocking, 
behind  the  inner  malleolus  ;  and  when  signs  of  irritation  of 
the  skin  are  observed,  a  very  useful  application  is  an  ointment 
of  hazeline  and  lanoline  gently  rubbed  over  the  part  at  night. 

Groups  of  small,  slightly  raised,  bright  red  spots  on  the 
skin,  somewhat  resembling  psoriasis,  are  also  met  with, 
chiefly  about  the  inner  side  of  the  knee  and  the  outer  side 
of  the  thigh.  These  spots  appear  usually  after  long 
standing,  and  most  commonly  in  cold  weather ;  they  cause 
much  itching  and  burning,  for  which  the  lanoline  and 
hazeline  ointment  is  a  suitable  application,  and  they 
rapidly  disappear  with  rest.  Sometimes  after  much  stand- 
ing or  prolonged  walking  bright  red  patches  appear  on 
the  legs,  attended  by  a  sense  of  heat,  but  not  of  itching. 
The  redness  disappears  on  slight  pressure,  and  fades 
gradually  after  a  day  or  two  of  rest.  These  conditions 
are  much  benefited  by  the  hot  bath. 

There  is  seldom  any  subcutaneous  oedema  such  as  gives 

6 


82  Phlebitis  and  Thrombosis 

rise  to  pitting  on  pressure,  but  there  is  usually  some  per- 
manent enlargement  of  the  affected  limb.  I  do  not  think 
that  this  increase  in  the  size  of  the  limb  is  due,  as  was 
suggested  by  Sir  James  Paget,^  to  muscular  growth,  but 
I  believe  it  depends  upon  an  increase  in  the  intermuscular 
and  subcutaneous  cellular  tissue :  for  the  outline  of  the 
muscles  and  their  visible  contraction  is  obscured,  and  the 
muscular  power  of  the  limb  is  diminished,  not  increased. 
The  morning  and  evening  measurements  of  the  limb  will 
be  found  to  differ  considerably,  and  this  is  certainly  due 
chiefly  to  fulness  of  the  vessels,  though  it  may  partly 
depend  upon  intermuscular  oedema. 

Moreover,  in  two  of  the  cases  related  by  Sir  James 
Paget  ^  the  enlargement  of  the  limbs  disappeared  under 
the  use  of  friction  and  the  hot  douche,  which  would  hardly 
have  been  the  case  if  it  had  been  due  to  muscular  growth. 

The   measurements  which   I    had  the   opportunity   of 

taking  in  a  case  nine  years  after  blocking  of  the  femoral 

and  external  iliac  veins  were  :  Sound 

limb. 
Morning  circumference  of  thigh...  =2o|  i^^chesl^^  j^^j^^^ 
Evening  „  „     ...  =2i|      „      J 

Morning  „  calf  ...  =13!      „      \^ 

Evening  „  „     ...  =14        ,,      / 

Sir  Prescott  Hewett^  speaking  of  the  after-history  of 
cases  of  phlebitis,  says :  '  When  seen  in  after-years,  the 
condition  of  the  limb  in  these  cases  of  blocked  veins  has 
varied  very  much.  In  a  few  the  limb  recovered  its  usual 
appearance,  save  perhaps  a  very  slight  increase  in  its  size, 
in  no  way  interfering  with  the  freest  action ;  for  I  have 
known  one  gentleman  who,  after  an  attack  of  this  kind 

1  '  Clinical  Lectures  and  Essays,'  p.  307.  Medical  Times  and  Gazette, 
March,  1858,  p.  261.  Here  Sir  James  Paget  says  that  he  has  not 
dissected  a  case,  and  *  can  only  guess  that  there  is  a  real  overgrowth 
of  muscles.' 

'■^  '  Clinical  Lectures  and  Essays,'  p.  305. 

^  Transactions  of  Clinical  Society  of  London,  vol.  vi.,  p.  xxxvii. 


Phlebitis  and  Thrombosis  83 

which  confined  him  to  his  couch  for  months,  returned  to 
deer-stalking  with  as  much  zest  and  activity  as  before. 
In  other  cases  the  Hmb  remained  more  or  less  swollen,  and 
consequently  with  its  action  more  or  less  interfered  with, 
the  circulation  being  carried  on  by  anastomosing  veins, 
largely  increased  in  size  and  tortuous.' 

The  bones  of  the  affected  limb  may  appear  to  be  en- 
larged, but  examination  by  the  Rontgen  rays  shows  that 
this  is  due  to  increase  in  the  subperiosteal  connective 
tissue,  not  to  osteal  growth. 

After  some  years,  as  the  obstructed  venous  return  is 
compensated  by  the  development  of  the  collateral  veins, 
the  enlargement  of  the  limb  may  disappear  or  greatly 
lessen,  its  shape  becoming  more  natural  and  the  outline 
of  the  muscles  more  apparent.  This  improvement  will 
be  aided  by  hot  baths,  followed  by  gentle  rubbing  in  the 
direction  of  the  venous  current,  by  moderate  use  of  the 
limb,  and  by  elastic  support  to  the  veins. 

The  heart,  of  course,  has  much  extra  work  thrown  upon 
it  by  venous  obstruction,  and  when  exercise  is  first  re- 
sumed in  a  case  of  blocked  vein  dyspnoea  is  easily 
provoked  ;  care  must  therefore  be  taken  to  put  no 
needless  strain  upon  the  heart,  as  by  rapid  walking  or 
ascending  hills.  It  should  be  remembered  that  if  the 
resistance  in  the  vessels  is  such  as  the  heart  can  overcome, 
hypertrophy  of  the  heart  takes  place  to  meet  the  increased 
resistance  ;  but  that  if  the  resistance  is  greater  than  the 
heart  can  overcome,  dilatation  of  the  heart  results. 

But  gentle  exercise  is  good,  and  sunlight  and  pure  air 
are  very  beneficial ;  for  the  better  the  oxygenation  of  the 
blood,  the  more  easily  it  circulates,  and  the  less  is 
the  fatigue  of  muscular  action.  Moreover,  the  more 
thoroughly  the  blood  is  oxygenated  the  less  prone  is  it  to 
thrombosis.      It  has  been  proved  that  the  inhalation  of 

6—2 


84  Phlebitis  and  Thrombosis 

oxygen  gas,^  or  even  the  increased  intake  of  oxygen  by  rapid 
respiration, 2  diminishes  the  coagulabiHty  of  the  blood. 

The  sufferer  from  blocked  veins  who  wishes  to  reduce 
the  inconvenience  to  a  minimum  must  live  temperately  on 
light  diet ;  be  careful  to  avoid  constipation  or  faecal  accu- 
mulation ;  take  moderate  exercise  early  in  the  day,  and 
rest  in  the  evening;  avoid  hurried,  severe,  or  prolonged 
exertion  ;  clothe  warmly  but  lightly ;  keep  out  of  hot  and 
ill-ventilated  rooms ;  breathe  pure  air,  and  seek  the  sun. 

The  necessary  limits  of  the  time  allotted  to  these 
lectures  has,  of  course,  obliged  me  to  omit  much  that 
might  have  been  said  upon  this  most  interesting  subject — 
the  coagulation  of  the  blood  within  the  living  vessels ; 
but  one  thing  which  will  probably  have  become  apparent 
is  the  small  amount  of  our  certain  knowledge  concern- 
ing the  blood — that  wonderful  living  fluid  which  carries 
life  and  nourishment  to  every  tissue,  giving  to  the  body 
its  power  of  action  and  of  feeling,  and  to  the  brain  its 
power  of  thought  and  memory ;  which  is  so  delicately 
constituted  that  by  the  invasion  of  a  minute  organism  and 
the  raising  of  its  temperature  two  or  three  degrees  it  may 
be  so  profoundly  altered  that  the  whole  body  at  once  be- 
comes disturbed,  action  impeded,  and  thought  confused ; 
and  which,  if  it  should  undergo  clotting  within  the  vessels, 
is  changed  from  a  source  of  healthy  action  to  a  cause  of 
mortal  danger,  or  even  of  sudden  death. 

I  say  how  little  we  really  know  of  the  vital  chemistry 
and  physiology  of  the  blood.  Here  is  a  wide  and  fertile 
field  for  our  advancing  physiological  chemists.  I  have 
only  endeavoured  in  these  lectures  to  make  some  contri- 
bution to  our  clinical  knowledge,  and  to  give  some  hints 
which  I  hope  may  be  useful  in  the  treatment  of  what  is 
often  a  troublesome  and  sometimes  a  dangerous  disease. 

1  Wright,  Brit.  Med.Journ.,  July  14,  1894,  p.  57. 

2  Hasebroek,  Zeitschrift f.  Biologic,  1882,  p.  41. 


INDEX 


Abdominal    operations,   throm- 
bosis after,  42 
Abscess,  ischiorectal,  28 

thrombotic,  28 
Alcohol,  effects  on   coagulability 

of  blood,  72 
Ammonia,  effects  on  coagxilability 

of  blood,  73 
Aneurism,  formation  of  clot  in,  16 
Angina  pectoris,  20 
Aorta,  thrombosis  of,  17,  18,  20 
Appendicitis,    causing    pylephle- 
bitis, 26 
thrombosis  and  embohsm  in, 
40,  41 
Arnott  on  phlebitis,  27 
Arteries,  injury  of,  16 
ligature  of,  16 
thrombosis  of,  15,  16 
wound  of,  16 
Arteritis,  gangrene  in,  19,  20 
obliterating,  16 
syphilitic,  16 
Artery,  cerebral,  thrombosis  of,  17 
coronary,  thrombosis  of,  20 
pulmonary,  thrombosis  of,  48, 

69 
pulmonary,  embolism  of,  47, 
53,77 

B 

Bacillus  infliienscE^  40 

Bacillus  proteus  valgaris  in 
thrombus  32 

Baillie,  Mathew,  on  oblitera- 
tion of  vena  cava,  61 

Baldwin,  cases  of  appendicitis, 

41 

Ball,   A.   Brayton,  on   throm- 
bosis of  cerebral  sinuses,  64 
Ball  thrombuSj  15 
Barthelemy   on   diabetic   gan- 
grene, 20 
on  syphilitic  phlebitis,  35 


Baxjmgarten  on  thrombosis,  10 
Beckman  on  thrombosis  of  renal 

veins,  69 
BizzozERO  on  blood-plates,  4 
Blood,  coagulation  of,  3,  73,  84 

carbonic  acid  in,  39 

in  chlorosis,  38,  39 

defibrination  of^  6 

fluidit}.'  of  2,  ID 

in  hemophilia,  39' . 

influence  on  vessels,  3,  9,  10 

in  influenza,  40 

in  jaundice,  73 

laky,  9 

lime  salts  in,  36 

platelets,  3,  4,  11,  18,  32,  38 

in  t\-phoid  fever,  36 
Bone,  acute  necrosis  of  23,  29 

effects  of  blocked  veins  on,  83 

necrosis  of,  in  t^.'phoid  fever,  38 
Briggs,  J.  B.,  on  recurring  phle- 
bitis, 44 
Brodie,  T.  G.,  on  coagulation  of 

blood,  8 
Brown,  W.  H.,  case  of  arterial 

thrombosis,  19 
BucKMA-STER,  G.  A.,  on  blood- 
plates,  8 


Calcium,  effects  on  coagulability 
of  blood,  8 
in  blood  of  typhoid  fever,  36 
Calhoun,  H.,  on  blood-plates,  6 
Carbonic  acid  in  blood,  39 
Cerebral  arteries,  thrombosis  of,  17 
Cerebral  sinuses,  thrombosis  oi, 

39^  02,  64 
Chaucer,  description  of   septic 

phlebitis,  27 
Chlorosis,  blood  in,  32,  38,  39 
Citric     acid    as     a     decalcifying 

agent,  ^j,  72 
Coagulation  of  blood,  conditions 

of,  2,11 


85 


86 


Phlebitis  and  Thrombosis 


Coagulation  of  blood,  diminished, 

74 
increased,  3,  73 
process  of,  3,  8 
COHNHEiM    on    coagulation    of 
blood,  3 
on  cedema,  55 
CORDER,  A.  H.,  on  phlebitis  after 

abdominal  operations,  42 
CORNIL  on  oedema,  56 
Coronery  arteries,  thrombosis  of, 

20 
Corpus  cavernosum,  thrombosis  of, 
35,70 

D 
Daguillon  on    recurring  phle- 
bitis, 44 
Davis,  D.,  on  phlegmasia  dolens, 

23 

Diabetic  gangrene,  20 

Dickinson,  W.  H.,  on  cerebral 
thrombosis,  17 

Dickinson  Lee  on  influence  of 
carbonic  acid  on  venous  throm- 
bosis, 38 

Disintegration  of  thrombi,  14 

DONNfi  on  blood-plates,  4 

Duckworth  on  thrombosis  in 
corpus  cavernosum,  70 

Duodenal  ulcer,  thrombosis  in,  42 


Eberth  on  blood-plates,  11 
Embolism,  14,  33,  45 

septic,  15 

pulmonary,  47,  53,  77 
Endocarditis,  15 
English  on  gastric  ulcer,  42 


Fagge,  Hilton,   on  thrombosis 

of  cerebral  veins,  66 
Fairbank,  cases  of  appendicitis, 

Fever,  blood-plates  in,  32 

typhoid,   relation    to   throm- 
bosis, 36 
typhus,    relation    to    throm- 
bosis, 38 
thrombosis  in,  16 
Fisher,  T.,  thrombosis  of  renal 
vein,  69 


Gangrene  in  arteritis,  18,  19 

of  intestine,  20 

senile,  20 

diabetic,  20 
Cask,  G.  E.,  cases  of  appendi- 
citis, 41 
Gastric  ulcer,  thrombosis  in,  42 

vein,  thrombosis  of,  65 

H 

Haemophilia,  blood  in,  39 
Hcemorrhoidal  veins,  thrombosis 

of,  68 
Halliburton  on  coagulation  of 

blood,  8 
Hawkins,  H.  P.,  cases  of  appen- 
dicitis, 40 
Heart,   effects   of  blocked  veins 

on,  83 
Hewett,  Prescott,  on  blocked 
veins,  82 
on  gouty  phlebitis,  34 
on  thrombosis  of  upper  limb, 

46 
on     thrombosis     of    corpus 
cavernosum,  jo 
Hill,    Leonard,    on    carbonic 

acid  in  blood,  39 
Hodgkin's  disease,  thrombosis  in, 

33 

Hoffmann,    E.,    on     syphilitic 

phlebitis,  36 
HORDER,    T.    J.,    on    blood    in 

influenza,  40 
Humphry,   G.  M.,   on  coagula- 
tion of  blood  in  veins,  58 
on    thrombosis    of   cerebral 
veinS;,  62 
Hunter,  John,  on  blood,  10 
Hutchinson,    J.,     on    arterial 

thrombosis,  18 
Hyaline  thrombus,  13 

I 

Iliac  veins,  relations  of,  45 
Inflammatory  thrombi,  13 
Influenza,  arterial  thrombosis  in, 
16 
blood  in,  40 
Influenzal  bacillus,  40 
Ischiorectal  abscess,  28 


Index 


87 


J 

Jaundice,  influence  on  coagula- 
bility of  blood,  T^ 

Jones,  Lawrence,  cases  of  ap- 
pendicitis, 40 

JULLIEN  on  syphilitic  phlebitis,  36 

K 
Keen,  W.  W.^  on  thrombosis  in 

typhoid  fever,  37 
Kemp,  G.  T.,  on  blood-plates,  6 
Knapp,  H.  H.  G.,  on  thrombosis 

in  typhoid  fever,  36 


Lane,  A.,  case  of  thrombosis  of 
cerebral  sinuses,  62 

Lazarus-Barlow  on  oedema,  56 

Lecithin,  effects  on  coagulation  of 
blood,  8 

Lee,  R.,  on  phlegmasia  dolens,  24 

Lett,  H.,  cases  of  appendicitis,  40 

Ligature  of  arteries,  16 
of  veins,  21,  25 

LOCKWOOD,  cases  of  appendicitis, 
41 

M 

Mackenzie,   F.  W.,  on  phleg- 
masia dolens,  25 

Mesenteric  veins,  thrombosis  of, 

65 

Milk,  decalcification  of,  72 
hme  salts  in,  36 

Milk  diet  in  typhoid  fever,  rela- 
tion to  thrombosis,  36 

Moullin,     Mansell,    case     of 
thrombosis  of  vena  cava,  60 

MuiR,  Robert,  on  blood-plates,  5 

Murchison    on    thrombosis    in 
typhus  fever,  38 

N 

Nervous     system,    influence    on 
oedema,  56 

O 
Obliterating  arteritis,  16 
CEdema,  causes  of,  54 

influence  of  nerves  on,  56 

in  thrombosis,  57 
Ogle,  J.  W.,  on  ball  thrombi,  15 


Ord,  W.  W.,  case  of  thrombosis 

of  renal  vein,  68 
Organization  of  thrombi,  13,  ']^ 
Ormerod,  case  of  thrombosis  of 

upper  limb,  46 
OSLER  on  arterial  thrombosis,  18 
on  blood-plates,  4,  32 
on  blood  in  fever,  31 
cases  of  thrombosis  of  portal 
vein,  67 
Osteomyelitis,  23,  29 


Paget,  J.,  on  gouty  phlebitis,  34 

on  idiopathic  phlebitis,  42 

on  enlargement  of  limb  in 
consequence  of  blocked 
veins,  82 

on  pulmonary  thrombosis,  49 

cases  of  thrombosis  of  upper 
limb,  42,  46 
Pakes,    W.    C,    on    bacilli    in 

thrombus,  32 
Pelvic  operations,  thrombosis  in, 42 
Petrone  on  blood-plates,  7 
Phlebitis,  22 

gouty,  34 

idiopathic,  26,  42 

non-infective,  54 

recurrent,  44 

septic,  23 

syphilitic,  22,  35 

suppurative,  26 

tubercular,  22 

treatment  of,  71 
Phleboliths,  14 
Phlegmasia  dolens,  23 
Pitt,  Newton,   on    pulmonary 
thrombosis,  48 

on  venous  thrombosis,  50 

on    thrombosis    of   cerebral 
sinuses,  63 
Pneumonia,  thrombosis  in,  16,  40 
Portal  vein,  thrombosis  of,  66 
Pulmonary  embolism,  17,  53,  "j"] 
Pulmonary  thrombosis,  48,  69 
Pyaemia,  27,  28 
Pylephlebitis,  26 

R 

Ranvier  on  cedema,  56 
Recklinghausen,      Von,     on 
thrombosis,  10 


Phlebitis  and  Thrombosis 


Red  thrombi,  1 1 

Renal  veins,  thrombosis  of,  68 

Rheumatism,  arterial  thrombosis 

in,  i6 
Richardson,  W.  B.,  on  coagu- 
lation of  blood,  73 
ROLLESTON,  H.  D.,  case  of  abdo- 
minal thrombosis,  66 
case  of  phleboliths,  15 


Septic  phlebitis,  23 

Senile  gangrene,  20 

Skin,  effects  of  blocked  veins  on,  8 1 

Small-pox,  thrombosis  after,  46 

Smith,  Wilberforce,  case  of 

thrombosis  in  phthisis,  47 
Spermatic  cord,  thrombosis  of,  36 
Splenic  vein,  thrombosis  of,  69 
Syphilitic  arteritis,  16 
phlebitis,  22,  35,  36 


Thompson,  R.,  cases  of  appen- 
dicitis, 41 
Thrombi,  ball,  15 

disintegration  of,  14 

formation  of,  2,  10 

hyaline,  13 

inflammatory,  13 

organization  of,  13,  Tj 

red,  II 

septic,  15,  23,  27 

white,  1 1 
Thrombosis,  arterial,  15,  16 

causes  of,  2,  11 

cerebral,  17,  39,  62 

chlorotic,  38 

idiopathic,  26,  42 

pulmonary,  48,  69 

recurring,  44 

venous,  20,  31 


Tobacco-smoking,  influence  on 
coagulability  of  blood,  T^ 

Turner,  F.  Q.,  cases  of  throm- 
bosis, 33,  46 

Turner,  G.  R.,  cases  of  appen- 
dicitis, 41 

U 
Uterine  phlebitis,  24 


V 
Varix,  thrombosis  in,  33 
Varicocele,  thrombosis  of,  33 
Veins,  blocked,  75 

remote  effects  of,  81 
inflammation  of,  22 
ligature  of,  21,  25 
obliteration  of,  58 
wounds  of,  21 

W 
Watson  on  obliteration  of  venae 

cavce,  59 
Welch,  W  H.,  on  thrombosis, 

12,  39,  67 
Wilson  on  obliteration  of  vena 

cava,  61 
WOOLDRIDGE  on  blood-plates,  7 
on  coagulation  of  blood,  9 
on  thrombosis,  22 
Wright,  A.  E.,  on  coagulaton  of 
blood,  8 
on  carbonic  acid  in  blood,  39 
on  decalcification  of  milk,  36 
on  lime  salts  in  blood,  36 
on  thrombosis  in  typhoid,  36 


Zoege-Manteuffel  on  arteritis, 
16 


THE   END 


Bailliere,  Tindall  &=  Cox,  8,  Henrietta  Street,  Covent  Garden 


DUE  DATE 

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